“Painkiller,” the new Netflix series about the origins of the opioid crisis largely created by the despicable machinations of the Sackler family and Perdue Pharma, could not be better timed. Just three days ago there was another development in the fall of the Sacklers, as the U.S. Supreme Court temporarily blocked the implementation of the 2021 $6 billion deal in federal bankruptcy court that would have blocked future opioid lawsuits against family members, who added to their vast fortune by creating and peddling OxyContin to complicit doctors and unsuspecting members of the public.
OxyContin was introduced in 1995 as Purdue Pharma’s breakthrough drug for chronic pain. The company employed an unethical marketing strategy that family scion Arthur Sackler had pioneered decades earlier, lobbying doctors to prescribe the drug and increase its dosage by dangling gifts, free trips to “pain-management seminars,”( aka all-expenses-paid vacations), paid speaking engagements, and ego-stroking visits from comely sales reps with cheerleading credentials.
Though the drug was marketed as “smooth and sustained pain control all day and all night” when taken on a 12-hour schedule, the alleged scientific evidence backing that conclusion was bogus. Purdue Pharma knew about widespread OxyContin abuse, including reports that the pills were being crushed and snorted; stolen from pharmacies; and that some doctors were being charged with selling prescriptions. After all, the drug was almost identical to heroin.
When the scandal finally broke in 2000, investigators discovered internal company memos sent between 1997 and 1999 that included the words “street value,” “crush,” and “snort.” The memos were written before company executives testified to Congress that they had no idea that the drug was being abused until a Maine law enforcement official issued a public statement about an “epidemic” in his state. In 2003, the Drug Enforcement Administration found that Purdue’s “aggressive methods” had “very much exacerbated OxyContin’s widespread abuse.” That was an understatement.
This horrible story of Big Pharma, corporate America and government-private sector collusion has been told several times already, notably in the Hulu series “Dopesick.” There seems to be near unanimous critical opinion that “Painkiller” is dramatically inferior to “Dopesick,” but that may be because “Painkiller” is more interested in ethics than it is in drama. Indeed, as drama the series is annoying: the direction is what I would term obtrusive, showboating, and overly aggressive. The ethics lessons that are explored in “Painkiller,” however, are worth pondering, as depressing as they are. For example:
- The dangers that loom when the super-rich (the Sacklers are multi-billionaires) are flat out sociopaths are terrifying. The same is true of major corporations run by sociopaths. How many are, I wonder? What can be done about that?
- The Sackler family covered its tracks in the time-honored way of giving lavishly to the arts, endowing museums, and generally following the same proven cognitive dissonance-exploiting path as the robber barons like Carnegie, Rockefeller, and other vicious industrialists like Henry Ford. They marketed the family name as belonging to admirable, trustworthy people, when they are, in fact, predators.
- “Money corrupts” is the familiar message that comes through again and again. “Painkiller” follows fictional blonde, shallow, soul-less sales representatives who happily manipulate male, middle-aged horny physicians to do Perdue’s dirty work, after which the women receive bonuses and snazzy cars. As outrageous as their conduct is, it is fictionalized, but not fiction. When one of the sales reps tearfully tells prosecutors that she never realized how “money could mess with your head,” I wanted to strangle her.
- An ethics villain whose name is worth remembering is Curtis Wright. He was the FDA official who initially questioned the safety of OxyContin and could have blocked it, but after intense and secret lobbying by Perdue executives, gave it a pass, approving an unprecedented label for the drug that stated, “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” The lesson: that’s how deceit works. “Is believed” is meaningless. Wright soon left the FDA and eventually was hired by Perdue after some intervening stops that were probably engineered by the grateful Sacklers.
- More deceit and fake appeals to authority: Perdue’s sales reps routinely cited a “study published in the New England Journal of Medicine” as proving that only a tiny percentage of those who were prescribed opioids ever developed an addiction. There was no such study. There was a four-sentence letter written by Jane Porter and Hershel Jick, M.D., describing addiction-related outcomes for the Boston University Medical Center’s patients who had been prescribed opioids. The letter’s authors were shocked that their narrowly-focused comment had been employed this way. Of course, none of the doctors who were given this false information bothered to check on it, though the pretty messengers had no medical credentials at all.
- More betrayals: Jay McCloskey, the Maine Attorney General who initially sounded the alarm about exploding OxyContin addictions in his state, later accepted a lucrative consulting contract with Perdue.
- And there’s this: when it looked like criminal charges might put the Sacklers in prison, some well-placed phone calls resulted in the Bush Justice Department knee-capping the prosecution with a minuscule plea deal.
Whatever its dramatic and production flaws, “Painkiller” is a festival of terrible ethics, just like the real life horror that inspired it.
Ethics Alarms 
The only ethical situation for prescription drugs is no advertising. Period. Same as cigarettes. Advertising about conditions, that’s okay; ethical advertising about suggested solutions, talk to your doctor about the condition (not about any specific drug). I brought up a WSJ article to a doctor one time, about a condition I had, and he rightly pointed out that you can’t just read one article, you have to read them all. Prescription drug advertising is, and is allowed to be, exactly the opposite — talk to your doctor about our drug. The 1st Amendment is not unlimited; there are other amendments, underlying concepts, etc. Some limits have been described by the Supreme Court. Drug advertising is another good place to set down some markers on what the limits to free speech should be.
Here’s Johnny,
Don’t know if I agree with you.
The limits of the First Amendment is probably false advertising.
The legal profession went through this.
It had been considered distasteful for lawyers to advertise their services.
But, there is a First Amendment and advertising can provide you important information (like the fact that, if you were ever stationed at Camp LeJeune, you may be entitled to a cash settlement). But, lawyers are held to an ethical standard in how they advertise.
Prescription advertisements are a hazard of having free speech.
-Jut
But the ads aren’t the problem, are they? Who cares what the public sees? The issue is the doctors, who are supposed to evaluate drugs by research reports, tests and literature. The ads can be useful, dumb as they are, for alerting the public to what’s out there.
Taken in isolation for an individual the ads may not be a problem but in the aggregate, it seems as though these ads are indoctrinating society that drugs make life worth living. If wea re going to indoctrinate to populace, we should be promoting healthier living and not drugs to combat the effects of unhealthy living. And just because you are allowed to advertise drugs it does not mean that you should.
I thought the primary role of the FDA was to ensure that what the drug company was attesting to was true and complete. I think it would be hard to require a physician to verify accuracy of sales information on every product the doctor may find necessary to prescribe. If a pharmaceutical company can falsify data to obtain FDA approvals, then we need to have the double-blind trials conducted by a third party.
However, if a physician makes a decision based on some idiotic assumption that the comely pill pushing lass might be willing to go to bed with him or her, he or she has no business in the medical profession.
Follow the Science! If the experts tell you it’s okay, no problem! It’s only wrong to follow your doctor’s advice if he tells you masking doesn’t work and the COVID vaccine is flawless.
*cough.
I mean, if he tells you the COVID vaccine is flawed.
I apologize for the length of this post, but the topic is complicated and does not lend itself to sound bites. What follows is my experience and opinions based on working in the pharmaceutical industry and extensive reading on my part.
Full disclosure: I am a retired pharmaceutical company executive. During my career, I worked for various cosmetic and pharmaceutical companies. I held positions in R&D, manufacturing, quality control, and supply chain management. For most of my career, I was responsible for a major Pharma manufacturer’s anticancer and biologics global supply chains. As a point of reference, I have not seen “Dopesick” or “Painkiller”. I am familiar, however, with the travesty the Sacklers perpetrated on the sick and society. The best summary of their unethical and probably criminal behavior I have read is in an LA Times May 5, 2016, article:
https://www.latimes.com/projects/oxycontin-part1/
Based on my experience, Perdue Pharma’s actions are not typical of the major pharmaceutical manufacturers. I am familiar however with at least one generic vitamin manufacturer who slapped a 3-year ex-date on their product knowing it lost 50% of its potency within 6 months of manufacture. This, however, is not life-threatening. Likewise, many generic manufacturers in China and India have questionable quality practices. Major Pharma companies have too much to lose to engage in the same practices that Perdue did.
As it relates to Perdue Pharma and the Sackler family, except for the death penalty there is no punishment too severe for them to be subjected to. They represent what can happen when the lust for financial benefit replaces science and ethical business practices. Except for mob-style hits, the Sacklers appear to operate their company much the way the Corleone family conducted business in the Godfather movies. I believe most major pharmaceutical companies operate in an ethical manner. The Sacklers are known to trade in favors and apply leverage to achieve the ends that they wanted. If you read the entire LA Times article, you will see that Purdue was aided and abetted in foisting fraud on pain patients by physicians, FDA officials, Federal and State Justice Departments, judges, government regulators, and politicians. All the individuals were bought off or influenced one way or another by Purdue to look the other way. Purdue could not have defrauded the sick without the willful cooperation of the aforementioned. It is also known that some physicians operate drug distribution mills. They charge a fee to write scripts for pain meds knowing they are not used to treat a medical condition.
Patients are not blameless either. When being prescribed a drug, you should question why a particular drug was selected. Question what therapeutic effect you should expect and what other treatments are available for your condition. If you have a drug that is not working, you need to demand alternative drugs or treatments. This is particularly true if your condition requires long-term use of a medication(s). In my opinion, you should not blindly put something in your body. You should do so only with informed consent. If your physician balks at this, you need a different physician.
Doctors prescribe a particular drug or treatment for one of three reasons: their experience with successfully treating other patients with similar maladies, their reading of medical journals, or they will try new drugs based on the promotional efforts of a drug company’s sales representatives. To the best of your ability, you should educate yourself on a medication’s side effects and treatment alternatives. This is very important because doctors’ compensation models are built on the quantity of patients seen, not the quality of care delivered. This is not to suggest that most doctors do not provide high-quality care. Rather it is just a statement of fact. The physician’s compensation model is basically piecework or as with attorneys in billable hours.
Early in my career, before PC speech rules, the pharma industry sales representatives were called “Detail Men” or “Bag Men”. The reps were well-schooled in the benefits of using the company’s drugs. They were also proficient in flattery and schmoosing techniques. They would arrive with bags of promotional materials and goodies to distribute to the medical and office staff. Once in the door, medical staff, doctors, and nurses that hit certain prescribing thresholds were presented with opportunities to earn honorariums promoting the drug company’s products to other professionals at local or distant conferences. The bribes work; otherwise, the companies wouldn’t spend the money. The entire lobbying industry in DC and State capitals is predicated on this business model.
Regarding pharma’s direct advertising to patients, I think it can do more good than harm provided patients do their own homework. For example, I suffer from Psoriatic Arthritis. My rheumatologist suggested I try one of two biologic drugs for my condition. After my own research, I explained I wanted to try a new drug being touted on television. My review of independent research showed it was just as efficacious as the drugs suggested by my rheumatologist but had only 1/4 of the side effects. We went with my choice of drug with positive results. Patients need to research and advocate for themselves. Patients should look at independent research papers and medication websites and then speak with their physicians to reach a mutually agreeable decision on treatment. I like rxlist.com but there are others. I stay away from the websites put up by the drug manufacturer and blogs of other disease sufferers. Physicians are not Gods. They are hired help. You are ultimately responsible for your healthcare.
Great post Tom.
What Chris said.
It is a good post, but…
Patients are not experts, most of them probably not good at research, and like legalese, “medicalese” is similarly difficult to follow.
Most people aren’t mechanically inclined or steeped in car repair, and knowing anything outside putting in gas or filling the windshield washer fluid in it’s reservoir requires an investment in time learning about and doing it. And not everybody can do it in any case. I do a lot with cars, I modify them for performance and looks all the time (and get compliments from strangers on my efforts!) but I can’t diagnose to save my life, or I’d have opened my own shop years ago.
People know they got a bad mechanic when the car still doesn’t perform after they pay to fix it, and doing that with doctors is has infinitesimally higher consequences.
Sorry, when you sign up to be a doctor, you sign on for a higher level of responsibility for knowing exactly what the hell you’re prescribing and the side effects, and are ethically responsible for “doing the least harm”.
There are a lot of factors today that I think add to the pressure of compensation, and I only know the less than half of it, but I can take a guess based on what I’ve seen and heard.
There was an anesthesiologist at our church, we went for meals and made friends as a result of the church pushing small group affiliations among the body. Among the memories of our gatherings was his comment that a lot of his associates were getting out because the cost of malpractice insurance. That was 10 years ago or better, and today, doctors have largely resorted to forming groups to cover increasing overhead costs related to that and other requirements.
Today, good luck finding a group of doctors that are taking new patients, and if they are, good luck getting an appointment inside of 3 months. And that’s on the quick side.
So good luck and best wishes finding a different physician if the one you’re seeing isn’t on board with what you are asking about prescription alternatives. In the meantime, you get to suffer without remedy.
Ultimately, the ethical choices should outweigh the monetary, but in this day and age, and much to Jack “Don Quixote” Marshall’s lament, ethical analysis and activity are in increasingly short supply.
(Jack, we appreciate, well, I, but I’d like to think I speak for all of us, that you continue this endeavor – I pass along links all the time in hopes of growing your audience, so if I’ve used the Don Quixote reference poorly, please accept my apologies in advance – well, apologies to all the learned peoples here if my ignorance shows. It was meant to convey that your noble efforts seem lost on society these days.)
Oh, the Don Quixote reference is apt…for my life, for the blog, for the entire ethics field. “Painkiller” once again made that all too clear….
Bad Bob,
“Patients are not experts, most of them probably not good at research, and like legalese, “medicalese” is similarly difficult to follow.”
30 years ago, I would agree with your comment. Today, because of the internet, people are uninformed because more likely than not they don’t put the effort into being informed. “Medicalese” becomes understandable with a simple extra internet search. I urge people to manage their healthcare themselves because they have the most to lose.
Regarding the problem with finding a doctor, I contend that is the fault of our government more than anything else, not pharmaceutical companies. I am in the process of preparing a post on that topic for either a Friday open forum or a host post if Jack is so inclined to offer me an opportunity. What the politicians and government agencies are doing to healthcare in this country is irresponsible and unethical.
Regarding the high cost of malpractice insurance, there is an argument to be made that some of that is fueled by irresponsible or unethical trial lawyers. The best example I know of involved silicone breast implants in the 1990s. This article gives a good overview of the non-problem made into a problem that unjustly crippled an industry.
https://www.healthaffairs.org/doi/10.1377/hlthaff.15.4.206
“In 1992 the Food and Drug Administration (FDA) responded to public concern by banning nearly all uses of silicone implants. Within two years approximately 20,000 lawsuits were brought against implant manufacturers. When a 1994 class-action settlement set aside $4.25 billion to pay damages, a quarter of a million women—20 percent of implant recipients—claimed to be ill and therefore eligible for compensation. The largest manufacturer, Dow Corning, filed for bankruptcy protection in 1995.”
True mostly with internet searches for medical info. I find the more info I want to know about something, the more I encounter “academic” literature, but the basics are sure there.
And if course it’s been true always that you need to advocate most assertively with or against your doctors on matters of your own health. My Dear Sainted Mother provided that lesson to us years ago, and had she not fought with the doctor, and sister in law!, I’d not have my two brats, who are treasures beyond words. They were about to do a hysterectomy on my then wife (definitely NOT needed to cure what ailed her).
Too unfortunately, I think a lot of people defer to the wisdom of these medical experts without question. And the sister in law was not necessarily stupid, she had a master’s in psychology.
The reference to how difficult it is to find a doctor was probably a knee jerk reaction to “if your doctor won’t work with you on meds find a new one” (paraphrase…) statement and the fact that struggle is real, since the physician we just got on with last year left the practice last month for far away lands. And his office mates weren’t taking in his patients. Not much to do with pharmaceuticals, my apologies there.
I do look forward to your posting on the hazards facing the medical system, lot of meat on that bone, and I’m sure I only see the tip of the iceberg.
Bad ethics rot, not only from the top but from the bottom as well. The blame for the misuse of drugs lies also with the user. The user who “crushes”, “snorts” or “injects” what is in oral pill form prescribed for legitimate reasons is as much if not more responsible for the crisis both personally and pandemically. I have prescribed and have been prescribed “pain medications” for pain. I have never “crushed,” snorted, or injected” pills. I stopped the pills when the pain subsided. It is the decision of the end user to engage in the abuse of the drug that leads to addiction.
That was, according to the series and the book it’s based on, the initial strategy of Perdue when the walls were closing in: blame the addicts. So all their public statements, including the statements made to Congress were about how the company couldn’t be blamed for those who abused the product. But the “12 hour” effectiveness claim, which prescribing doctors blindly followed, made regular users into junkies, as their pain became unbearable well before the limit, leading then to over-dose, gradually turning them into junkies. Drug stores, meanwhile, saw absurd levels of the drug being purchased by single users, and never noticed. But the Sacklers knew the drug was the equivalent of heroin, and it doesn’t take a genuis to figure out what would happen if heroin was a prescription drug.
“the drug was almost identical to heroin.” Did the series make a big deal of this? Chemically its structure is closer to good ‘ol morphine, but it doesn’t really matter – oxy, morphine, and heroin are all opioids. They all carry risk of tolerance and addiction. Heroin’s structure specially suits it to enter the brain quickly and powerfully, making it more addictive even than fentanyl, despite the fact that fentanyl is far more potent (meaning a much smaller amount is needed for an equivalent effect on the body’s opioid receptors).
I work in a hospital and we use oxycodone pretty freely after surgeries. But now, almost 30 years after it entered the market, no provider doses standard oxycodone q12 hours. It’s always q4 or q6 hours. Lesson learned by now. It’s maddening that it was ever marketed as a twice daily opioid, since its half-life isn’t much different from other common opioids like morphine. Pharmacokinetic information like that is available to pharmacists, and should be readily available to doctors.
Not a big deal, just used for emphasis by, for example, the FDA doctor who questioned its safety.
Last year, at age 68, I finally took responsibility for my own healthcare, as one commenter suggested. Throughout most of my life I have been very healthy, having little contact with the healthcare system, except for employer-required physicals, a couple of bouts with the flu and a minor injury or two. That all changed in 2017 when I went to the doctor in regard to an infected spider bite. Blood work done during that visit led to diagnoses of hypertension and Type 2 diabetes. I had not previously shown signs of either of these disorders. I won’t bore you with the details, but within the next year I had my gallbladder removed, and had spinal surgery to relieve acute stenosis that had made me unable to stand or walk. I spent fifteen months in a wheelchair before I was able to walk again using only a cane. Being confined to a wheelchair brought its own set of digestive and circulatory issues, and subsequent drug treatments. I developed atrial fibrillation about a year after I began walking again, and subsequently underwent a cardiac ablation procedure to correct the a-fib.
It was my own dissatisfaction with the drugs I was being prescribed (side effects and interactions) that led me to research my health issues and look for alternatives to endless rounds of prescription drugs and surgeries. I began to read up on the links between nutrition and health, particularly in regard to my own diagnosed problems. My conversations with my doctor quickly revealed that she really knew very little about nutrition. Medical doctors are taught only two treatments: prescribe a petrochemical drug product or cut out some tissue. Medicine or surgery, take your pick. The pharmaceutical companies have tremendous influence on not only drug prescribers, but on the medical schools, the AMA, and the healthcare industry as a whole. Purdue’s excesses are just the tip of the iceberg,
A year ago last month, I began as a patient at a natural health clinic that emphasizes nutrition as both treatment and preventative. This clinic’s caseload is booming as many people (notably including many medical professionals) grow disheartened by traditional medical practice, in no small measure due to the Wuhan Flu fiasco, and seek alternatives.
As my knowledge of nutrition has grown and my personal nutrition has improved, so has my overall health. I am down from six prescription medications to only one (insulin). My current doctor is weaning me from the insulin as my blood glucose numbers improve. I expect to be drug-free within a year. I have read extensively about the pharmaceutical industry’s long-standing efforts to actively suppress nutritional remedies and other natural healthcare alternatives. The information is out there if you look for it.