2.6.2019 / OPIOID MARKETING
Several years ago, I had this surgery. They cut open my face.
It was pretty intense.
When it was over, the hospital sent me home with a prescription for Oxycodone for the pain.
It was waaaaay more intense.
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I took one of the pills. I got dizzy. I got anxious. I started slurring my words.
It was way worse an experience than the surgery!
I stopped taking the Oxy and realized... <Scoring gone>
I didn’t need the drugs. I wasn’t even in pain.
But then I started wondering why I was given such potent painkillers in the first place.
My best guess was pharmaceutical companies are really powerful.
And now there’s a study that suggests my guess wasn’t all that bad.
GERMAN: A study found recently that there seems to be a direct correlation between marketing for opioids so like these drug companies send representatives to these doctors and directly market to them telling them ‘hey you should prescribe our drug, it's going to be safe, effective,’ etc. And there's a correlation between that kind of marketing and prescribing rates and opiate overdoses a year later.
German Lopez writes about legal and illegal drugs for Vox.
He says this new study isn’t the first to suggest that doctors are influenced by marketing from pharmaceutical companies.
GERMAN: One study that came out last year looked at sending these doctors to conferences, giving them paid travel, speaking fees that kind of thing. But one of the points in this paper is that some of the most effective marketing might be more subtle things, like just buying a meal and that alone will influence whether doctors prescribe the drugs.
Marketing these jagged little pills starts to really ramp up in the mid-90s.
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GERMAN: In the mid 90s, OxyContin came out and that led Purdue Pharma, which created it, to really start ramping up advertising and marketing campaign for it.
PURDUE PHARMA AD: There's no question that our best strongest pain medicines are the opioids. They don't wear out, they go on working. They do not have serious medical side effects. And so these drugs which I repeat are our best strongest pain medications should be used much more than they are for patients in pain.
GERMAN: It said that the drug was safe and effective. That doctors could prescribe it and they would see these dramatic benefits for people suffering from both acute pain and chronic pain. And at the same time other pharmaceutical companies jumped in and started advertising their opioids, started saying hey, joining with Purdue like these are safe and effective. We have these new types of drugs ready to go out to patients. And this is really where we saw the opioid crisis start. It started with with these doctors because not only do these drugs go out to patients but because patients at so many of these pills they would sell them, they would keep them in a medicine cabinet where their teenagers could then go on and steal them. They would give them to friends or family. And since a lot of the advertising a lot of the marketing at the time was like ‘Hey these drugs really aren't that dangerous,’ a lot of people were genuinely duped by this. They thought that for whatever reason these opioids on the market at the time were safer and more effective.
PURDUE PHARMA AD: These are the same drugs that have a reputation for causing addiction and other terrible things. Now, in fact, the rate of addiction amongst pain patients who are treated by doctors is much less than 1 percent.
GERMAN: This was part of a campaign at the time to really just take pain more seriously. There have never been very good treatments for chronic pain. And so when opioids came in and they were advertising this new sexy, safe effective drug, a lot of people were ready to buy that.
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SEAN: What was the major difference between say oxy and the preexisting painkillers that were out there? Why did it take off in such a big way?
GERMAN: So the big thing that they advertise is that they use this extended release formula and they're slowly absorbing into their body and it's slowly taking effect.
SEAN: Yeah.
GERMAN: That's going to be less risky than if they take a pill that takes effect all at once, right? SEAN: Yeah.
GERMAN: That was the thinking and the thing is like well a patient will also need fewer of these pills.
SEAN: Hmm.
GERMAN: Since they'll only had to take one for eight to 12 hours. I should clarify that a lot of this is turns out to have been extremely misleading like Purdue had evidence fairly early on that its drug was not working as long as it advertised.
SEAN: Hmm.
GERMAN: And the Los Angeles Times had a great report on this basically finding that they kept advertising this as long lasting anyway.
SEAN: Even though they knew it wasn't.
GERMAN: Yeah, even when they knew it really wasn't. But the key thing here is that even with his extended release Formula… one way to get around it is to crush a pill and snort it or inject it.
SEAN: Hmm.
GERMAN: And so that would make all of the opioid in their take effect at once. It's an extremely easy way to get around the medication essentially not getting you as high as you would want to right away.
SEAN: Did Purdue know what it was cooking up in the 90s when it came up with Oxy? Did it know that it had like this blockbuster drug on its hands?
GERMAN: It certainly seemed to based on how aggressively it marketed it really wanted to sell as many opioids as possible get as many doctors prescribing them as possible.
SEAN: I mean how big an industry does this become?
GERMAN: Up to this point, Purdue it's big on its own has made tens of billions of dollars from Oxy. Other companies are by making way more because in the end Oxy is still only a part and a small part of the overall opiate market. I mean there's Percocet. There’s morphine is still a big part of our like how patients get opioids in hospitals There a fentanyl products.
SEAN: Yeah. Vicodin. Codeine. Demerol. Did these companies have any idea how addictive all these painkillers were?
GERMAN: They definitely should have known. I mean we've known for centuries that opioids are addictive just about everyone who's been using opium for like thousands of years could tell you that right. And even people who took like oxy as prescribed got addicted and some of them overdosed and died. So Purdue really should have known that this this product is not safe it's not effective. It truly does help some pain patients but it just wasn't as safe and effective as Purdue said it was. And now we're all facing the consequences of this and the opioid epidemic.
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This is Dr. Daniel Young. I am a family physician in upstate New York. And over the last five years I've transitioned into teaching younger physicians during their three year training program.
Doctors are visited by pharmaceutical representatives from many different companies in the office. I was seeing pharmaceutical representatives, probably one or two a week where they would come to the offices to tell me about any new medications they might have out on the market. They would bring the information in that way. Or they would, there was a lot of conferences going on. I remember going to a pain conference, probably in the mid 90s to learn more about how to treat chronic pain.
You know all of the literature and the pharmaceutical information was that we had these longer acting pain medications and patients did not become dependent or addicted to the medication.
So I think it definitely shifted what I was doing. I definitely increased the amount of long acting pain medication that I was providing to patients, absolutely.
I would start getting more patients coming to my office. You know if you were a physician who prescribed you know the chronic pain medications you would suddenly start getting more and more patients as friends you know would refer their friends to you. So, yeah, definitely like a light bulb goes off saying hey something's not right here. You know these are probably patients that should not be on chronic pain medication.
We’re out there to help people, not to cause them harm and I definitely think that over the years we've probably been some patients that I have caused harm by creating either dependence or addiction on pain medicine.
[MIDROLL]
SEAN: So German, when exactly did the first signs that you know oxy and other opioids like it might be extremely addictive start to surface?
GERMAN: So it happened pretty early on. By the late 90s and in the early 2000s, we had already seen opiate overdose deaths start rising, particularly painkiller deaths.
SEAN: Yeah.
GERMAN: There were stories all over the news. You can look back at archives of people talking about misusing drugs, using them at parties and that kind of thing. I mean one of my favorite things here is that if you go back to like old TV shows...
SEAN: Hmm!
GERMAN: Like if you rewatch Friends, there are jokes about misusing opioids and how they're making you feel high and all that stuff.
SEAN: On Friends?!
GERMAN: Yeah.
CLIP <FRIENDS>:
MONICA: How do you feel?
ROSS: I feel great, I feel gweat.
MONICA: Wow, those pills really worked, huh?
ROSS: Not the first two, but maybe the second two….
GERMAN: It's a bunch of like 90's shows that you would think are more innocent. They do make these kind of remarks here and there.
CLIP <WEST WING>:
CJ: Mr. President, did you by any chance take your back pills?
PRESIDENT: I don’t mind telling you, CJ, I was in a little of pain there.
OTHER GUY: Did you take the Vicodin or the Percocet?
PRESIDENT: I wasn’t supposed to take them both?
GERMAN: I'm like really sensitive to this stuff.
SEAN: *lol*
GERMAN: Obviously, I'm like what what the hell are they talking about these drugs are not like OK to just joke about like this. I mean I was in high school when I got my wisdom teeth removed and I got some opioids as a result of that. And my friends were all joking about like ‘Hey are you getting high, can we try some?’, that kind of thing.
SEAN: Yeah.
GERMAN: But at the end of the day it's it just goes to show like these drugs are really going everywhere and everyone at some point seemed to know that they could be misused. And yet you still saw this kind of marketing.
SEAN: Did anyone hold these companies like Purdue and its peers accountable for this in the 90s, the way let's say you see President Trump for example talking about it now, at least?
GERMAN: No, it's not until like the mid 2000s where you start seeing government, law enforcement really start to crack down. So actually in 2007 Purdue ended up paying $600 million dollars in fines…
SEAN: Huh!
GERMAN...because of its misleading marketing and some of its executives were wrapped up in this too, having to pay fines on their own and then they had to do go out and do community service as a result of that. So, in the end that's like peanuts compared to the billions of dollars literally that they have made from opioids. So it's a question of like were they held accountable enough or for them was it just like a cost of doing business as they saw their profits grow anyway.
CLIP <MASS. ATTORNEY GENERAL MAURA HEALY> This morning, my office filed a lawsuit in Massachusetts state court against Purdue Pharma, and its board members and executives.
SEAN: Jumping ahead to present day opioid crisis. There are now several lawsuits that suggest Purdue might actually get in more, and perhaps more serious trouble. Who are the executives these lawsuits target?
GERMAN: So you do hear a lot about the Sacklers, meaning the Sackler family which owns Purdue. Umm, they're really wrapped up in all of this because not only have were they involved in the creation of oxy but they also were involved in the marketing of it.
CLIP: <COLBERT>--If the Sackler’s haven’t done enough damage, they also just patented a new drug to help wean addicts off opioids. So, the Sacklers addicted the country to opioids, now they’re going to profit off the cure? That takes a pair of swinging Sacklers. <laughter>
GERMAN: Some recent lawsuits filed by Massachusetts Attorney General, the findings in there suggest that the Sacklers or at least some members of the Sackler family knew that these drugs were dangerous, knew that they were leading to all sorts of trouble, and still they tried to cover that up. And that they pushed them to market the drugs more aggressively.
CLIP <MA AG Maura Healy>: They don’t want to accept blame for this. They blame doctors. They blame prescribers. And worst of all they blame patients. When you say that, do you mean Purdue or the Sackler family, or are they one and the same? They’re one and the same.
CLIP: In one alleged instance, then President RIchard Sackler devised what Healy describes as Sackler’s solution to the overwhelming evidence of overdose and death, writing in a confidential email, “We have to hammer on the abusers in every way possible. They’re the culprits and the problem.”
GERMAN: Now Purdue will come back and say that the findings in that lawsuit are misleading or taking some of their communications out of context. But generally we do know that Purdue was very aggressive in marketing this and the Sacklers had to be involved in some way given that they own the company in that kind of marketing.
SEAN: Is that is that lawsuit now settled or is it ongoing?
GERMAN: No, the Massachusetts lawsuit is relatively new. But there are I mean literally hundreds of lawsuits around the country against not not just Purdue but all sorts of pharmaceutical companies and also distributors. So like Walgreens for example is wrapped up in some of these lawsuits because the argument is also that these distributors should have known that they were supplying a bunch of these drugs to people who should not be getting them. A bunch of those lawsuits, like again, literally hundreds are now being consolidated in Ohio, and the hope is that will lead to some sort of big settlement agreement that will once and for all tamp down on not just opioid prescription but also provide money that can then be directed to addiction treatment and prevention.
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SEAN: Is the problem bigger than that though? I mean you're talking about dealing with addiction and dealing with the misleading marketing of these opioids. But like as you said and as I said like I got a moderately serious surgery, did not need any painkillers really and I was sent home with Oxy. You had a dental procedure and you were sent home with Oxy. Like this has become a part of this country's medical culture.
GERMAN: And you see this in the statistics. Even though since 2010 there's been a drop in prescriptions for opioids overall.
SEAN: Okay.
GERMAN: America still prescribes way more than any other country. I mean there are different ways to measure this. But when you look at the statistics like the second place country it is like not even close, overall opiate prescriptions America is way ahead.
SEAN: I mean why the heck is it? Why is that even the case that we're above and beyond any other country in terms of our usage of these drugs?
GERMAN: If you're a chronic pain patient you're suffering from like serious pain, general pain, it's like debilitating, you go to the doctor and the doctor wants to find a solution for you but the doctors also under pressure to see as many patients as possible throughout the day. That's how they get the most money out of essentially this system. So if you're faced with that like are you going to talk through the patient about how there might be psychological factors in their pain? Are you talking about how it might involve lifestyle changes and all of that stuff? Or, are you gonna give them a pill? And like if you're under pressure to do this as quickly as possible the pill is the easiest answer. Now there are a lot of good doctors out there who who do not want to do that because they know that these opioids are risky. But even like well-meaning doctors facing this kind of pressure the scales are just tilted against them. They they are pressured to essentially give out these pills, it's the easiest answer.
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GERMAN: In other countries, if you talk to like Japanese doctors for example they will tell you that it's kind of expected that you will just have some pain at some points in your life. And if you talk to doctors here, they feel like they're under more pressure to make sure that there is zero pain in somebody’s life. The other thing is while there are some patients who do benefit from these drugs in terms of like acute pain specifically and in terms of chronic pain, the evidence that they are actually better than other treatments for chronic pain is really weak, like there's there's almost no scientific basis for that.
SEAN: Hmm.
GERMAN: The studies have been found that there are similar results whether you give somebody opioids or whether you put them on some other drug regimen sometimes involving like Tylenol.
SEAN: Yeah.
GERMAN: And that's because over time opioids, you grow tolerant to them so they just become less effective.
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GERMAN: When I donated a kidney I personally said I do not want opioids because they make me nauseous. They don't actually don't help my pain. I still got opioids! Like that I had trouble like telling the nurses and doctors involved like please do not prescribe these drugs. I mean it's a serious surgery so I can see why they would want to. But at the same time if somebody is telling you I don't want these dangerous drugs like maybe listen to them.
SEAN: What’d you take for the pain instead?
GERMAN: I just took extra strength Tylenol.
German Lopez is a senior correspondent at Vox.
You heard from a doctor earlier in the show. He came to us via The Impact, which is another Vox podcast you should listen to.
I’m Sean Rameswaram.
This one’s Today, Explained.