How an ER doctor and a Purdue Pharma whistleblower think about the opioid crisis

The gang’s all here.
The gang’s all here.
Image: Kira Bindrim/Quartz
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Purdue Pharma has received heaps of criticism for the role it played in the US opioid epidemic. After a year-long investigation, Quartz found that Mundipharma—an international network of companies also owned by the Sackler family—is using similar deceptive marketing to sell opioids overseas

On Aug. 20, Quartz members joined editor in chief Kevin J. Delaney for an advance screening of How to Sell Drugs (Legally), a Quartz documentary that came out of our investigation. The screening was followed by a discussion between Delaney, director Lucy King, and two subjects who appeared in the film: Carol Panara, a former Purdue sales rep turned whistleblower, and Dr. Chris Johnson, an ER doctor and board member of Physicians for Responsible Opioid Prescribing.

If geography or other commitments kept you from attending the screening, we’ve got you covered. The full documentary is here, and for highlights from the event, keep reading.

Okay, so what’s the issue again?

Purdue Pharma, owned by the Sackler family, is the maker of OxyContin. The company has not only faced public pushback for its role in the opioid crisis, but in 2007 Purdue was found guilty of downplaying the risks and overstating the effectiveness of opioids. The company also used legal marketing practices to boost sales, despite knowing the risks of addiction and dependence. These tactics are now at the center of a host of lawsuits against opioid manufacturers and distributors; those suits are currently making their way through the courts in Ohio.

Now, Mundipharma (Purdue’s international arm) is deploying that same marketing strategy to Europe and other emerging markets.

What are the experts saying? 

Here are some memorable quotes from our HQ discussion. 

“I remember hearing rumors early on that the bonuses for the Purdue sales reps were just incredible. Some of them were making $50 or $60,000 a quarter in incentive bonuses.”—Carol Panara, former Purdue sales rep

“I’d like to tell you that doctors are good scientists and they’re skeptical. What you find in the private practice of medicine in America, is if you’re generating positive numbers, a lot of the questions don’t get asked.”—Dr. Chris Johnson, ER doctor and board member of Physicians for Responsible Opioid Prescribing. 

“If a doctor’s concern was addiction, we could say, ‘If you’re going to use an opioid, you need to know that the risk of addiction is the same for all of them. So let’s focus on who would be an appropriate patient for this specific product.'”—Carol Panara

“Here’s the problem with a capitalist society: They have an incentive in you consuming more health care. You being healthy on your own isn’t good for business.”—Dr. Chris Johnson

Take me inside the discussion.

Here are some salient questions and answers from our HQ conversation, edited for length and clarity. 

Quartz member: I spent at least 5 years living on a pain scale of nine out of 10. I’m also a corporate strategist. The question I have is: What’s next? Because there will always be supply and demand. There’s always going to be sick people. Western medicine doesn’t do really well for chronic pain. So what’s the next step?

A different Quartz member: There are a few people in the United States that have started projects to develop non-opioid, non-addictive drugs for chronic neuropathic pain. So that’s the solution to the problem. That’s what people should be focused on next. And not ignore a problem, obviously, but there will never be a solution until there are new drugs. 

Lucy King (director of How to Sell Drugs (Legally): It’s true, lots of pharmaceutical companies are developing non-opioid products at the moment, but it’s in the future.

Quartz member: Can you talk about cannabis? It’s a $100 billion projected market, and states like Illinois are pushing that cannabis can be an adjunct therapy or even a replacement for opiates. How, from clinical point of view, is that real? Is it not real? Is it marketing? 

Johnson: I don’t know the data on cannabis and you’d still have to have a double-blinded, controlled trial showing improvement over a year to two years. And conducted by people without financial conflict of interest doing the study. That was actually the SPACE trial done for opioids two years ago. SPACE stands for Strategies Prescribing Analgesic Comparing Effectiveness. It showed no improved pain control and quality of life with opioids, but higher rates of complication, which is exactly what the public-health data show us for the last 20 years. You do a double-blinded, controlled prospective trial. Otherwise, spare me. 

Quartz member: Is it a question of value-based care, where you’re paying for a patient to get healthier, versus fee for service? You’re saying, “Let us know how many opioids you want. We’ll just keep paying out there.” Versus value-based care: “We’re paying for you to get better and then we reimburse practitioners based on how healthy a patient is.”

Panara: I think an issue that needs to come up is that pain is subjective. It’s not like blood pressure, where they take a measurement and give you a medicine and that will lower it. What could be excruciating for you may not be as bad for someone else. But then the other issue, too, is that people who are in pain think that they need to take a medicine to totally eliminate all their pain. And maybe the the objective needs to be more to be able to manage it and not necessarily bring you from a 10 down to one. 

Quartz member: I work in the public health industry outside of the US. And my big concern is that a lot of the rhetoric that happens in the US trickles over in a very negative way and affects access to lifesaving drugs. A lot of vaccine hesitancy and demand is negatively influenced by people that otherwise are not looking for chronic-pain medication. I’m curious as to what responsibility the industry in the US and a lot of European countries have towards the negative impact that pharma and the industry are having on people in the developing world who need basic medications to save their lives? 

King: That was a real concern of mine when I was making this film. I hope it didn’t come across that the pharmaceutical industry is entirely evil. And I hope it didn’t come across that opioids were entirely evil, either. I think we need pharmaceutical companies. The challenge is to have them come in an ethical way. And to regulate them in a way that doesn’t oversaturate the need. Or to provide the right medicines, and not just the medicine that makes the profit. 

Quartz member: What is the lifespan of “good” patient on opiates versus a “bad” patient on opiates? And why isn’t there an ethics committee that extends to pharmaceutical companies like it does with doctors? 

Johnson: I don’t like to divide into good patients and bad patients. We used to say there’s legitimate pain and illegitimate pain. Nonsense. It’s just pain. Pain is an emotional experience, and we’re not going to tell someone their emotional experience is not legitimate. And let’s remember that everyone in here is on opiates. This is what your endorphins are. Every brain is on opiates and that’s why they don’t work for very long. What we do know is that once a person who develops opiate use disorder, things are grim. About one in five are dead in 10 years. It’s about a 2% mortality per year, which is what your average 68 year old has. And it’s not just necessarily all overdoses. You’re more prone to infectious disease. Once you develop the opiate use disorder, your chances of dying are about 18% in 10 years. That’s not good. 

Rather than say good and bad [patients], I would say when is [an opioid] indicated or not indicated? Who is the appropriate person to get it? When you break a bone, you have a kidney stone, you’ve got an abscess, you take it for a week to get over your injury. And then at the end of life where, honestly, if you become dependent, who cares? The reason you treat addiction is that addiction takes away your ability to maintain your work, maintain your relationships, all these things that are important for a healthy, independent human. Well if you’ve got metastatic pancreatic cancer, your disease has already done that.  So in those circumstances, that is perfectly fine for opioids. But there have been no studies showing that any chronic pain condition where opioids are effective long term and don’t cause complications. 

Quartz member: What would it take for there to be a pharmaceutical equivalent of the Hippocratic Oath, or an ethics board?

Johnson: With the passage the Affordable Care Act, something came into existence called the Open Payments Act. You can look up and see what doctors have taken gifts from pharmaceutical companies. And it turns out if you want to see where the most opioids deaths are, follow pharmaceutical gifts to doctors. Open Payments shows that half the doctors in this country take gifts from pharmaceutical companies. They’ve all taken the oath. Doctors are terrible at assessing how their influenced.  In my view, rather than relying on raising a hand and taking an oath, disrupt the incentives. Disrupt that reciprocity mechanism to get independent, and I would hope, more scientific thinking.