AMERICAN PAIN (10 page)

Suddenly, in the late 1990s, news stories about pain began to appear. Profiles of chronic pain sufferers who couldn’t get narcotic prescriptions due to doctors’ fears of addiction. Trend pieces about the prevalence of pain and its undertreatment. Purdue officials themselves were rarely mentioned, but the stories were peppered with quotes from Purdue-backed consultants and researchers and doctors. The stories created the general impression that tens of millions of Americans were suffering in needless pain.

Many of the stories were planted by groups like the American Pain Foundation. The foundation claimed to be a patient advocacy organization, but 90 percent of its money came from the drug industry, including big grants from Purdue. The foundation acted as a front for Purdue and other drugmakers, advancing pro-opioid policies in ways that the companies themselves could not. The foundation funded pain management web talk shows, published policy guides that plugged narcotics, and marshaled pain patients to send angry e-mails to reporters, prompting news stories about the stigma they had faced when seeking medication. It was a smart move, Golbom believed, because it created the impression that anyone who questioned the escalating use of prescription narcotics lacked empathy for people in pain. Only a heartless clod wanted to deny people in pain the medications they said they couldn’t live without.

Similar stories originated from new “grassroots” regional pain advocacy organizations that had sprung up, such as the Appalachian Pain Foundation, based in Huntington, West Virginia, which received a $20,000 grant from Purdue shortly after it formed in 2000.
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The foundation arranged a series of meetings in Kentucky and West Virginia to spread the word among local doctors that opioids were underutilized even in their pill-swamped communities. The doctor who co-chaired the foundation said the Purdue grant had no effect on the foundation’s work. Years later, he lost his medical license after airport officials found oxyco-done and hydrocodone bottles with other people’s names on them among his luggage. A subsequent investigation revealed that a number of his patients had died of overdoses.

Purdue targeted the doctors who controlled the prescription pads. Most physicians had received maybe an hour or two of pain management training way back in med school. They needed a re-education in painkillers, and Purdue supplied it with the largest narcotics marketing campaign ever. Between 1996 and 2002, Purdue funded more than twenty thousand pain-related educational programs, almost ten a day, seven days a week. During the same years, Purdue conducted more than forty national pain management training conferences at resorts in Boca Raton and Scottsdale, paying the travel costs for more than five thousand physicians who attended. More than twenty-five hundred physicians were on Purdue’s speaker bureau list. They went home with plush toys, fishing hats, CDs, and pens, all branded with the OxyContin logo. A favorite freebie was the heat-sensitive Oxy-Contin mug that bore the words: “The one to start with . . . .” When filled with hot coffee, the rest of the slogan materialized: “The one to stay with.”

The educational seminars made the most of the unfounded statistic that “fewer than one percent” of patients would develop addictions. One continuing medical education program sponsored by Purdue promoted opioid therapy as the only solution for chronic conditions such as back pain. The program contained a role-playing exercise in which a patient admits he is taking twice as many pills as he’s supposed to. An authoritative narrator cautions the doctor not to jump to the conclusion that the patient is addicted, even if he seems desperate. The role play ends with the doctor prescribing a high-dose opioid.

Purdue doubled its sales force during those years, from 318 to 767 pharmaceutical reps. In the trade, the reps are called detailers, and they’re typically good-looking, gregarious, and well-dressed. They remember the names of the clinic receptionists and secretaries and nurses. Purdue expected each drug rep to develop a list of 105 to 140 physicians within a specific sales region and call each one every three or four weeks. And they didn’t target only oncologists and pain management specialists. They went after family doctors and general practitioners, a broader and less painkiller-savvy prescriber. Purdue paid its reps better than most drug-makers paid theirs—by 2001, an average salary of $55,000 and an average bonus of $71,500. Purdue spent a half-billion dollars on the one-on-one sales strategy between 1996 and 2001.

Purdue drug reps also had another tool: OxyContin coupons. Free samples were a common way to promote a new medication, but the DEA didn’t allow it with controlled substances like OxyContin. So in 1998 and 1999, Purdue bypassed this rule by giving each rep twenty-five coupons for a free thirty-day supply of the drug. In 2000 and 2001, as OxyContin’s reputation grew, the company cut the free trials to seven days. Reps gave the coupons to doctors, who passed them on to patients. The freebies cost Purdue $4 million a year, but in the narcotics business, it was a good long-term strategy.

Purdue drilled its reps on two selling points. One, OxyContin was the first narcotic that wouldn’t hook patients. And two, fewer than 1 percent of pain-management patients get addicted anyway.

Purdue’s army of drug reps reminded Golbom of the salesmen a century earlier who peddled patent medicines like Hamlin’s Wizard Oil or Hostetter’s Celebrated Stomach Bitters, men who assured their customers that a bottle of snake oil would cure everything from arthritis to kidney disease.

The heart-and-minds campaign worked, beyond even Purdue’s expectations. Within a few years, OxyContin became a major pharmaceutical hit, one of the top-twenty brand-name medications in the United States. By 2002, six years after its release, Purdue was selling almost $1.5 billion of the drug each year—eight times the volume the company had projected. The single drug represented 80 percent of Purdue’s net sales. It was the biggest-selling brand-name controlled substance on the market.

The once sleepy drugmaker was now a powerhouse, and it wasn’t about to concede that its star product had a major flaw.

OxyContin’s warning label instructed users not to crush or dissolve the pills because the entire narcotic load would be released at once. In other words, do not powderize the pill . . . unless you want to get ecstatically, euphorically high. Abusers paid attention and realized how ridiculously easy it was to beat the pill’s timed-release formulation. Just crush it, and they’d get the whole thing at once. They could wrap it in foil and grind it between their molars, or take a hammer to it. Still, after ingesting it that way for a time, the knife-edge of joy became just a bit blunted. So abusers would try snorting it to get it to the bloodstream faster, boost the rush. And when that dulled, they could mix the powder with water, draw it into a needle, and shoot it straight into the vessel.

People began dying with OxyContin in their bloodstreams. At first, around the year 2000, the overdose reports were haphazard and anecdotal, a few dozen deaths tallied by a worried medical examiner in Virginia or a few hundred reported by a DEA researcher. News reports detailed a wave of OxyContin abuse that originated in rural areas with a tradition of pill dependency, such as western Virginia, eastern Maine, and Kentucky.

Purdue pushed back against the evidence. Just because oxycodone was found in a corpse’s bloodstream didn’t mean it came from an Oxy-Contin pill, company spokesmen said. And if there were other drugs or alcohol involved, as was often the case, how could you definitively blame oxycodone?

But deaths involving prescription narcotics continued to mount, until the trend was impossible to dismiss. Overdose deaths involving prescription opioids quadrupled between 1999 and 2007, from about three thousand to twelve thousand per year. By contrast, cocaine killed about six thousand users in 2007, heroin about two thousand. Prescription narcotics were now killing more Americans than all illegal drugs combined.

In fact, while the heroin years of the 1970s and the crack crisis of the 1980s had produced a frenzy of publicity, those outbreaks had barely nudged the overall drug death rate. The unintentional drug overdose death rate had hovered between one and two annual deaths per one hundred thousand citizens during the heydays of those drugs. By 2007, the overdose rate had shot up to about nine deaths per one hundred thousand, almost entirely due to opioid-related deaths. Pills were far deadlier than crack or heroin, but they didn’t create the same national hysteria.

There was a reason for this lack of outrage. Golbom noticed that almost every story about the increasing devastation quoted a pain management doctor or “expert” from one of the industry fronts like the American Pain Foundation. There was always a paragraph about the “undertreatment of pain,” with the implication that even more opioids were needed to solve the problem. Purdue had created a truth, backed up by a body of seemingly legitimate research and publication, and few seemed to question the underlying premise that OxyContin was an effective drug for chronic pain, safe “when taken as prescribed.”

It took Golbom time to fully comprehend the implications of Purdue’s strategy, but once he did, he realized its brilliance. The company was selling an addictive drug that it said would not addict you as long as it was
taken as prescribed
. Then, when the drug did addict someone, and they began taking too much of it, or hoarding it to take all at once, or trying to obtain multiple prescriptions or early refills—then, that person was no longer taking it
as prescribed
. That person became one of the outcasts, an addict, and therefore the “safe when taken as prescribed” dictum remained valid. Purdue seemed to regard those folks as a tragedy of their own making. But the company affirmed that its responsibility was not to addicts who were abusing the drug, but to the untold millions of pain sufferers who needed it.

Golbom wondered how many addicts had begun taking OxyContin under the care of a doctor. He came to realize that there was very little difference between heroin and opioid narcotics. Heroin had been stigmatized as a bottom-of-the-barrel drug, the destination of the dirtiest of street junkies. Whereas, “pain pills” had been systematically sanitized in the public’s mind. Even in the flood of news stories about oxycodone deaths, reporters and experts referred to prescription narcotics as if they were, at worst, a gateway to the hard stuff. As a pharmacist, Golbom could determine only two clear advantages OxyContin had over heroin as a recreational drug. One, OxyContin was legal. Two, it was pharmaceutical-grade—you knew exactly what was in it, unlike a bag of heroin bought on the street. Other than that, oxycodone addiction and heroin addiction were
the same thing
.

Nevertheless, Purdue had inflated the market for opioids, and other pharmaceutical companies rushed to meet the demand. They copied Purdue’s OxyContin marketing techniques. They re-educated doctors about narcotics, hired “key opinion leaders” to promote the drugs, funded pro-opioid medical education courses, funneled money to seemingly independent patient advocacy groups, and professional societies. And the companies developed one new opioid narcotic after another, hailing each as a breakthrough.