OxyContin

How misleading marketing got America addicted

On Feb. 10, drugmaker Purdue Pharma, creator of OxyContin, announced it had sliced its sales force in half and would stop promoting opioids to doctors, a problematic marketing strategy that pushed addictive pain pills and contributed to the nation’s opioid crisis, critics say.

Now Purdue, facing lawsuits from at least 14 states, says it wants to help fight addiction. “We recognize that more needs to be done and that’s why we continue to pursue a range of solutions that we believe will have a meaningful impact to help turn the tide of this national public health crisis,” it told The Washington Post.

Though Purdue is acting proactively now, it didn’t at first — and that original harm caused by OxyContin is hard to undo.

Twenty years ago, before prescription pills created a generation of addicts and before those addicts turned to heroin for cheaper highs, doctors almost exclusively prescribed opioids to suffering cancer patients and the terminally ill.

Washington Post illustration; iStock

Doctors knew opioids were addictive and not meant to treat the chronic pain of those with aches or arthritis. Then came Purdue with an opioid pill they called OxyContin and promises it was safe for all.

It wasn’t. But Purdue, through an unprecedented, aggressive and multifaceted marketing campaign that ran from 1996 until the early 2000s, persuaded doctors to prescribe OxyContin anyway — and helped kick-start the nation’s current opioid crisis. Here’s how.

Promotional videos

Shipped to tens of thousands of doctors, these promos pushed a narrative meant to grow Purdue’s customer base — and profits — by framing fears of opioid addiction as overblown roadblocks to compassionate pain care.

Doctors, paid by Purdue, were some of the company’s most prolific spokespeople in videos that appeared educational but were subtly marketing opioids.

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Courtesy of Dr. Andrew Kolody

The most impactful of the videos, titled “I Got My Life Back,” was sent to 15,000 doctors in 1998 but not submitted to the FDA — a violation of federal law.

It featured seven of Dr. Spanos’ patients and was named after the words of Johnny Sullivan, a construction worker with chronic back pain.

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Courtesy of Dr. Andrew Kolody

But as the truth about opioids surfaced in the years that followed, not even OxyContin’s featured patients were spared the deadly consequences. In a second video Purdue distributed in 1999, most of the original seven-patient cast was back, including a subdued Johnny Sullivan praising OxyContin’s effectiveness.

Nine years later, Sullivan was dead — killed in a car accident after he fell asleep at the wheel, which his wife has said in interviews was a side effect of his addiction to OxyContin and other prescription opioids.

JUNK SCIENCE

It was Purdue’s campaign to change the definition of addiction, and the numbers used to support this, that ultimately persuaded doctors to buy into the company’s narrative.

“It wasn’t what we heard directly from Purdue, but what we heard indirectly from pain specialists, hospitals, state medical boards,” said Dr. Andrew Kolodny, the co-director of opioid policy research at Brandeis University. “It became almost a movement, almost a religious-like fervor, around expanding access to opioids.”

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Courtesy of Dr. Andrew Kolody

But that “1 percent” statistic was, in fact, a manipulation of the truth, a conclusion based in part on a one-paragraph letter to the editor in the New England Journal of Medicine (NEJM) in 1980 that sampled only hospitalized patients — not those with take-home pills — and was never peer-reviewed.

In 2017, Canadian researchers found that the letter had been cited some 680 times in the nearly five decades since, prompting the NEJM to issue an editor’s note on the original 1980 letter “for reasons of public health.”

“I’m essentially mortified that that letter to the editor was used as an excuse to do what these drug companies did,” Dr. Hershel Jick told the Associated Press. “They used this letter to spread the word that these drugs were not very addictive.”

A NARROW TARGET: DOCTORS

An effective marketing strategy for Purdue was directly targeting those who control prescriptions through so-called educational conferences sponsored by the company in destination states such as Arizona, Florida and California, in addition to a massive, relentless sales force — at a time when the medical community was far less skeptical of “Big Pharma.”

The number of sales reps available for OxyContin promotion increased 73 percent in the seven years after the drug was released.

Tales of sales tactics by Abbott Laboratories, a partner of Purdue, are the stuff of legends: a box of doughnuts spelling out “OxyContin” for a hesitant doctor; $20,000 cash prizes and luxury vacations to top performing drug representatives; internal memos that call sales staff “crusaders” and “knights” and top executives the “Royal Court of OxyContin.”

BRANDED SWAG

It is standard practice for pharmaceutical companies to give branded pens and paper to doctors who might prescribe their drugs. It is not standard practice to do this for a controlled substance like OxyContin.

Nevertheless, Purdue pushed a cache of swag — golf balls and mugs, car shades and wrenches, sun visors and stuffed animals — that was unprecedented among Schedule II opioids, according to the Drug Enforcement Administration.

Courtesy of Art Van Zee

The swag, according to a 2003 U.S. General Accounting Office report on OxyContin, was “an indicator of Purdue’s aggressive and inappropriate marketing” of the drug. “Those things were circulated while young kids were dying from OxyContin,” said Virginia primary care physician Art Van Zee, who published a paper on Purdue’s marketing scheme.

Purdue’s tactics helped prompt the issuance of voluntary guidelines from Pharmaceutical Research and Manufacturers of America (PhRMA) and HHS’s Office of Inspector General for how prescription drugs should be promoted — guidelines that didn’t exist when OxyContin first hit the market.

MEDICAL JOURNAL ADVERTISING

Purdue more than sextupled its annual spending on ads in OxyContin’s heyday, from $700,000 in 1996 to $4.6 million by 2001. Ads appeared in reputable medical journals such as the Journal of the American Medical Association.

And three of those ads eventually got Purdue Pharma in trouble. The first that raised concern at the FDA — and one that exposed Purdue’s habit of manipulating science — ran in the NEJM on May 4, 2000.

In a warning letter to Purdue, the FDA called the ad misleading and said it violated the Federal Food, Drug and Cosmetic Act because it cited a narrow study of arthritis patients as evidence OxyContin should be used to treat all arthritis patients.

Two years later, FDA cited Purdue again for two more ads that were problematic. Both understated the serious dangers associated with taking OxyContin, such as death and addiction, and “grossly” overstated the “safety profile” of the drug, the FDA wrote. “The combination … is especially egregious and alarming in its potential impact on the public health.”

BIG PAYOUTS, BAD SIDE EFFECTS

All that marketing did pay off for Purdue, but in the mad grab for more patients, more pills and more money, the company helped spark an epidemic.

Purdue’s aggressive and misleading marketing of OxyContin contributed to a fourfold increase in prescriptions to treat cancer-related pain. But prescriptions for non-cancer pain — the kind that opioids were never intended to treat — increased tenfold.

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And all those prescriptions brought billions in revenue.

Purdue’s business margins relied on persuading doctors to solve the so-called pain crisis. Instead, they created an opioid one.

Purdue resolved criminal and civil charges by agreeing to pay $600 million in fines, and three top executives pleaded guilty to misbranding, a criminal violation. Those men paid a total of $34.5 million in fines.

But their old marketing scheme is still affecting Americans today, as the nation again reckons with an opioid crisis that just keeps killing.