We spoke to Brandeis University opioid policy expert Dr. Andrew Kolodny to get a sense of how to properly understand what has been happening.
“To start with, the correct way to frame the opioid crisis is an epidemic of opioid addiction,” Kolodny told us. “The reason we’re experiencing record overdose deaths and that we’re seeing fentanyl and heroin in parts of the country we’ve never seen it before, and outbreaks of injection related diseases, and births of opioid dependent babies, is all because of the increase in opioid addiction coming from prescription opioids.”
Noting the 900 percent increase in opioid addicts between 1997 and 2011, he said the majority of overdoses are among those already addicted. But this is by no means the whole story. “I have a friend who lost his daughter who was seventeen. It was the night before she was going to college, and she was at a party,” Kolodny said. “She was experimenting for the first time and took an 80 mg OxyContin which is a very high dose. One pill, and Emily died.
“That said, I really don’t agree with framing this as a ‘drug abuse’ crisis, because that implies we have a lot of people behaving badly and accidentally killing themselves while behaving badly and recreationally. Some people became addicted because they abused opioid prescriptions and liked the feeling, but more are dependent and continue to use opioids not because they feel good but because when they are not taking them they feel sick.
**
We now live in an America where working class, predominantly White, rural people whose parents and grandparents would have spat at the idea of shooting up are now living and dying with needles in their arms. And they are doing it in extremely large numbers. Many, including Dr. Kolodny, describe this as an “epidemic.” But is it really an epidemic? The world “epidemic” implies a disease spreading naturally, due to some pathogen. The “pathogen” idea makes it easy to get caught up in debating the best strategies or treatments for combatting this “natural occurrence,” just as you would an outbreak of the bird flu. It sounds inevitable. The only hope is to treat the disease and hope the “epidemic” subsides.
In truth, this crisis isn’t about a naturally occurring pathogen infecting the population. Centuries ago, it was possible to claim ignorance about the effect opiates have on patients. But the lessons of history are easy to learn if only we’d look. This wasn’t inevitable. There were guiding hands behind designing these drugs, obtaining regulatory approval, and marketing them to patients and doctors. Whether by plan or criminal negligence, this crisis wouldn’t have occurred without human action. Something set this in motion. Someone in the long chain of events that got us here were derelict in their duties or knew what they were doing. Maybe both.
Because this has both human intervention and a human death toll, maybe the more correct lens to view this through is not that it is an epidemic, but rather a crime. If one patient is deliberately and knowingly administered a deadly drug, we might treat it as murder, but now that the death toll is over 400,000, we call it an “epidemic”? What changes an event from a crime to a public health issue?
The full human cost is not simply an accounting of the dead, but includes the impact of despair and hopelessness that follows in the wake of opiate addiction and abuse. There is, as Adam Smith said, “much ruin in a nation.”
We began our investigation into this crisis by considering the places hardest hit by opiate addiction, overdoses, and deaths. To our surprise, the hardest hit areas were home to certain rural and working-class American communities—exactly those who had most successfully resisted drugs in the past.
The fact that “flyover America” is most affected by the crisis explains the relative paucity of coverage in the news. Rural White Americans are those least likely to receive sympathy from coastal media and politicians. Both the leadership of the left and right often take rural and working-class Americans for granted. But these Americans are part of the backbone of this country. They comprise a surprising percentage of our armed forces. They contribute a disproportionate amount to the Federal tax coffers. And historically, they have provided the labor that made America the industrial superpower of the modern world. Without them, America simply won’t be the same.
**
If a pharmacy fills two hundred prescriptions of all types on an average day, then today about twenty-five of those will be for opioids. That’s far and away the biggest single category of prescriptions filled in a pharmacy. That’s in every pharmacy in America, every single day.
* * *
In very large measure, this blizzard of opioid prescriptions really started with Purdue Pharma. “Blizzard” here is not a capriciously chosen word, by the way. According to court filings, a member of the Sackler family, owners of Purdue Pharma the maker of OxyContin, told attendees of the drug’s 1996 launch party that the drug’s takeoff would be “followed by a blizzard of prescriptions that will bury the competition,” according to filings and records produced in Massachusetts v Pursue Pharma et al. And he was right. OxyContin was the most successful pharmaceutical product launch in American history. It buried the competition in the years since. In that same period of time, OxyContin and its competitors also buried hundreds of thousands of Americans.
According to the CDC, from 1999 to 2017, more than 700,000 people died from a drug overdose. Around 68 percent of the more than 70,200 drug overdose deaths in 2017 involved an opioid. In 2017, the number of overdose deaths involving opioids was six times higher than in 1999, counting both prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl.
**
Viral videos of people overdosing in public are now too common, like that of Ron Hiers and his wife, Carla, who shot up heroin in a Walgreens in Memphis, Tennessee and passed out at a bus stop. As Time described it in an article and video titled “Life after Addiction,” Hiers is “bent backward over a bus-stop bench, eyes closed, head brushing the ground and a cell phone in his outstretched hand. It rings, but the man doesn’t move. A few feet away, dangerously close to the road, a woman lies face down on the sidewalk, her legs buckled under her. She tries to get up but can’t make it, and collapses back down in a heap.”
In another heart-breaking scene, a mother lies sprawled on the floor of the toy aisle in a retail store in Lawrence, Massachusetts. Her two-year-old daughter, dressed in pink “Frozen” pajamas, cries and screams, vainly trying to wake her mother up.
Such stories, unthinkable a generation ago, can be found all across White Middle America. Flyover America. The Heartland.
A grandmother and her partner in East Liverpool, Ohio, are found sprawled out in the front seat of an idling car while her four-year-old grandson, still dressed in dinosaur pajamas, sits in the back.
Even the survival stories can make you feel a bone-deep kind of sadness. In Jacksonville, Florida, a young woman candidly told a local news station of her struggles with opioids that started when she was prescribed them at the age of sixteen to alleviate the pain of ovarian cysts. Twelve years later, she was still fighting addiction.
“I remember doing the pregnancy test, putting it on the ground and shooting up while I was waiting for the test results to come back,” Crystal Harrison told First Coast News. “I was prescribed them for about two months, and when the prescription ran out I started looking in the street for them. I went from Lortab to Oxycodone to heroin to fentanyl, and all it was just, it’s been a downhill effect since I was sixteen until now twenty-eight.”
She’s had to be revived with Narcan three times. She sought treatment, and as of the time of her interview in the fall of 2018, she had been clean for six months and regained custody of her three children. Assuming she beats the odds and stays clean, the cost in lost time with her children and to her health has already been levied, and it’s all because of a drug she should have never been prescribed.
* * *
In a way, it’s simple. Their first taste came from a person they trusted most—their doctor. Some might sneer at “pill poppers” for a moral failing, but the number one way Americans are introduced to prescription opioids is when they get them for acute pain for minor or major surgeries. The second most common way is wisdom tooth removal. The average age of the recipients of opioids for wisdom tooth removal is around seventeen years old.
So, we turned to a different kind of doctor for some answers: Dr. Robert Valuck, professor at the University of Colorado Denver’s School of Pharmacy and Pharmaceutical Science. Valuck is a fit and gregarious man with grey peppered in his brown hair. He can hold forth on the broad scale and history of the opioid crisis, in part because he saw it unfold in real-time, but also because it’s a passion he has made a part of his field of study.
And he has no qualms about naming those he considers most responsible, the merchants of this crisis. “There’s a confluence of factors over a long period at play but you start in the early 1980s with the increased attention to treatment of pain and the recognition of pain,” Valuck says. “There was a lot of talk about the under-treatment of pain in the 1980s and in some ways there was a little truth to that, but the narrative was completely different. No one was talking about ideas like pain-free or ‘painkillers.’ I don’t like that word ‘painkiller.’ There’s no such thing.” Interestingly, addicts often describe opiates not as eliminating pain, but making it so they simply don’t care about the pain.
While the explosion of opioid prescriptions for pain treatment and pain management began in earnest in the early 1990s, Valuck said that one of the prime movers for the push cited by pain management experts, doctors, and especially pharmaceutical companies was something printed in the January 10th, 1980 issue of the prestigious New England Journal of Medicine.
It wasn’t a study or anything even close to so weighty. It was a single-paragraph letter to the editor. Here is the full text of it:
Addiction Rare in Patients Treated With Narcotics
To the Editor: Recently, we examined our current files to determine the incidence of narcotic addiction in 39,946 hospitalized medical patients who were monitored consecutively. Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had no history of addiction. The addiction was considered major in only one instance. The drugs implicated were meperidine in two patients, Percodan in one, and hydromorphone in one. We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.
Jane Porter
Hershel Jick, MD
Boston Collaborative Drug
Surveillance Program
Boston University Medical Center
“Even now the authors admit it wasn’t supposed to be carte blanche for opioids. This wasn’t a real study. It was basically a larger-case anecdote,” Valuck said. “This became something cited hundreds and hundreds of times as evidence for the fact that opioids were not addictive, if used legitimately. The claim was that it was less than 1 percent or one-tenth of a percent that became addicted and it showed no such thing.”
The truth was, Porter and Jick had analyzed a database of patients hospitalized at Boston University Medical Center. These were patients in a hospital given small doses of opioids for acute pain, not long-term pain. The drugs were administered by staff, not the patients themselves, and were delivered only in the hospital.
But pharmaceutical companies and pain management advocates were off and running. The Joint Commission is a prestigious national non-profit that accredits and certifies nearly 21,000 health care organizations and programs in the United States. They claimed that facilities needed to create a plan for addressing levels of pain and what to do about it. This sounds reasonable in and of itself – nobody wants to live in pain.
But consider the American Pain Foundation. While also official sounding and apparently reasonable, they were anything but. Valuck describes the American Pain Foundation as “a money laundering organization for the pharmaceutical industry.” Funding records bear this out. According to an investigation by ProPublica, fully 90 percent of its funding came from Big Pharma. It was the chief advocate for the proliferation of opioid pain relievers and expanded pain management as part of the medical practice for decades. That is, it was the chief advocate until it abruptly closed its doors in 2012, just as it came under intense Congressional scrutiny.
“The American Pain Foundation launched a campaign to make pain the ‘fifth vital sign,’” Valuck said. The Joint Commission joined them, and in 2001 rolled out its pain management standards which supported the idea of the fifth vital sign. “They said you have to assess and address it. They were not saying you had to use opioids but to assess and address it,” Valuck said. “That set the foundation.”
That may sound benign to a layman but think about it. What are the four things you get checked every time you go to see your doctor? It’s always body temperature, pulse rate, respiration rate, and blood pressure.
“Now, every person at every visit to the doctor would get assessed and asked about it,” Valuck said. “It would put the issue top of mind, and plant the idea that any pain they had should be treated. But pain is not a vital sign. It is a symptom.”
So, taking together all of this, Valuck said, you had a generation of doctors taught to think of pain as a “vital sign” and that any and all pain had to be managed or ameliorated. It created a culture where doctors and patients alike viewed pain not as part of the human experience, or a natural warning sign, or even as a consequence, but rather as something that had to be eradicated.
Concurrent with the rise of the concept in medicine of perpetual pain management and eradication came the inclusion of pain management as part of the patient experience with government payment plans. “Then there were discharge surveys for Medicare and Medicaid patients. Satisfaction surveys of care. Now granted... only a random sample of patients get these... but they were asked about how their pain was managed,” Valuck said. “And until only recently, scores on the pain segment were tied to higher and lower levels of reimbursement for the provider. I can’t think of a more perverse incentive for hospitals and providers to overprescribe.
“It created a perverse incentive to give everyone Vicodin. ‘Are you in pain? Have some Vicodin,’” Valuck said, mimicking the dismissive attitude.
But was it just misguided medical policies and a simple push from Big Pharma that got us here? “Don’t underestimate the power of marketing... the pharmaceutical companies never did,” Valuck said.
* * *
Big Pharma first marketed prescription opioids such as hydrocodone to treat pain. They claimed, leaning on the conventional wisdom of the Porter-Jick letter and what came after, that these drugs carried minimal risk for addiction. There are dozens of companies that manufacture and market opioids and synthetic opioids, but the biggest name in the business, especially when it comes to marketing, is Purdue Pharma run by the Sackler family.
Mortimer Sackler was the patriarch of the Sackler dynasty until his death in 2010. The second son of Jewish immigrants from Ukraine and Poland, Sackler and his three brothers became the leaders of a small pharmaceutical company in the 1950s. By the mid-1980s, Purdue Pharma was still a small concern, but Mortimer Sackler had big ideas on how to grow its product line.
“Mr. Sackler... is associated with a lot of well-known products like Valium and Librium, but he invented peer-to-peer influencing, thought leader influencing, and how to get doctors to sell to each other,” Valuck said.
That is to say, rather than relying on the typical “cute sales rep” that would go from doctor’s office to doctor’s office, Purdue spent tens of millions on programs to convince physicians to lean on one another to favor certain Purdue products over other pharmaceutical brands. Doctors, most of whom hold themselves in high esteem, naturally hold their peers and their peers’ recommendations in high esteem.
Purdue Pharma was a pioneer in campaigns geared towards patients directly, such as the “Get Your Life Back” campaign that was basically preparing the market for Purdue and the Sackler’s greatest achievement—the launch of OxyContin in 1996.
It all worked all too well.
“OxyContin was the most successful launch in the history of modern medicine,” Valuck says. By 2001, something like 80 percent of Purdue’s gross revenue of $3 billion came from OxyContin sales. And according to the New Yorker, OxyContin had generated for Purdue “some $35 billion in revenue” by 2017. The Sackler family had gone from owners of a relatively modest pharmaceutical company in the mid-1980s to the nineteenth wealthiest family in America in 2016, according to Forbes.
Pharmaceutical companies like Purdue and others continued the full-court press. Strategies included paying middlemen to get around state regulations and even going so far as to allegedly bribe doctors to prescribe opioid medications.
“They knew what was going on. They knew [OxyContin] was more addictive than they let on. They knew it wasn’t a twelve-hour medication. And it will eventually get proven in court,” Valuck said. “They’ve already paid multiple hundred-million-dollar judgments—they’ve already admitted that [it] doesn’t last as long as they claimed.”
More than forty states are involved in a multi-district litigation in Ohio. Hundreds of counties and municipalities have their own lawsuits. Whether Purdue survives or not is in the cards, but the damage to Americans has already been done. If the tobacco company lawsuits are any guide, little of the settlement money will end up in the pockets of victims. More likely, it ends up in government hands, which will then distribute it to corporate recovery programs with maddeningly ineffective recovery statistics. Either way, the price will be paid by Middle America.
Some media attention has been paid to the incredible body count the opioid epidemic has wrought, but there has been very little sense of emergency, and no sense of urgency. Not the way there was with the crack epidemic of the 1980s. Particularly not at the level of national policy and national media.
At the state level, some of the regions hardest hit have cracked down on “pill mills” where unscrupulous doctors took cash for prescriptions in storefronts that would pop up and disappear from month to month. And they’ve passed limits on the amount or duration of opioids physicians can prescribe. Of course, as mentioned before, this has only resulted in a grim game of drug choice “Whack a Mole” with those enthralled to opioid dependence seeking illicit sources like heroin and fentanyl.
The addictive nature of opioids has been known for over a century. Today, it isn’t simply anecdotal. We can almost measure the likelihood of addiction to the tablet. According to Valuck, there is a 6 percent chance a person given just 6 tablets will be taking opioids a year later. This comes from a survey of over half a million patients, not a letter to the editor of a medical journal. “And if you give a patient three weeks or more of tablets, say 60-90, there is a 20 percent chance they’ll be taking opioids a year later. Give them forty days—it’s a 40 percent chance. We know how this works,” he said. The calculus of opiate addiction is as consistent as it is depressing.
* * *
Many states have passed regulations limiting opioid prescriptions, and medical guidelines increasingly stress that opioids be avoided when possible for acute pain such as a new injury, or for patients who are post-op. There are new systems in various states where prescribers can look up a patient’s entire prescription history with other prescribers to ensure that the patient isn’t “doctor shopping.”
But there’s still the problem of illicit opioids, synthetics, and the persistent problem of those who have taken opioids for chronic, long-term issues.
“The most reduction has been in acute pain, but we’ve not gotten our hands on chronic pain, those who are physiologically dependent,” Valuck said. “There’s no real data to support opioids as long-term pain relief, and yet there are data emerging that people on opioids for longer periods are developing hyperalgesia,”—which is characterized by a patient receiving opioids potentially becoming, paradoxically, more sensitive to pain.
“These people aren’t addicts but they are physiologically dependent. In these cases, we’re really not treating pain but treating withdrawal. And they are teetering on the edge of addiction. It just robs the spirit and it robs a person of purpose,” he said. “Anyone can be tapered off but it takes time and commitment,” Valuck added. “That’s the next big challenge.”
**
Most people don’t associate Alabama with coal mining, but Jasper was once among the leading producers of coal. That’s part of the reason why there’s such a gap between the rich and poor here. It’s also why the area suffers problems similar to better-known coal areas like the towns in Kentucky and West Virginia. At its height there were half a dozen coal mines, two sandstone quarries, four hundred coke ovens and a foundry, according to the Daily Mountain Eagle.
Mining and its associated trades are hard, repetitive work that easily give injuries to the common workers, while making large profits for the owners. These injured workers were a natural target for pharmaceutical companies going back to the 1980s, when they began pushing for more aggressive treatment of pain.
“Physicians were prescribing it like crazy,” said Matt Brown, chief of staff at Addiction Recovery Care in Louisa, Kentucky. “We’re from coal country. It’s a lot of manual labor and a lot of injuries. And when the coal jobs go away, people still have their prescriptions. They have a dependence on the drug and a need to make money on the side.”
Government subsidies helped fuel Jasper’s addiction. As coal jobs started disappearing, Medicare and Medicaid ensured that retired or unemployed patients would still be able to get their medications. Moreover, the price of opioid tablets on the street was high enough in recent decades that many could sell pills to others while still having enough left to satisfy their dependence, perversely replacing some of the income lost to globalization. Ironically, patient health may have been at greater risk by having health insurance, Medicare, or Medicaid than not having it, due to the lack of interest the government showed in how it was being used and affecting people’s lives.
**
Allred has seen people come before him looking like they have every chance at getting cleaned up and their life back together, but too often it doesn’t work that way. He has pages of heart-breaking stories where he’s done everything he can for someone and he still gets word weeks or months later that they’re back in jail or dead. He’s seen people who actually get cleaned up do so too late and end up having severe medical problems from the damage they’ve already done to their heart or liver.
“You shouldn’t be thirty-three or thirty-four and having to deal with open heart surgery or liver failure,” Allred tells us. “The saddest thing for me though is seeing younger people, millennials, coming through here, and I can see exactly what’s coming for them and they don’t get it.”
He pauses for a moment and shakes his head. “Everything we do seems like it’s one step forward and two steps back,” Allred says. That’s not to say there hasn’t been progress, but Jasper has the same problem we observed in Kentucky. Even as they crack down on pill mills, heroin and Fentanyl slide right in to fill the gap.”
**
Adam is a slender man in his early fifties with piercing green eyes and a cautious demeanor. Joshua, in his early twenties, shares his father’s eyes and build. He’s an engineering student at an Ivy League university nearby.
Father and son share something besides their appearance. They share an addiction to opioids.
We’re at their house for the better part of a warm June day. It’s spacious and well appointed, in a classic style befitting the community. Adam’s wife serves us iced tea from a silver tray. Their family has roots in the area here that go back before Civil War. They’re deeply involved in the community and donors to the arts in Philadelphia. They don’t want to get more specific than that. The circles they run in are, in the end, a small world.
“I took a bad fall cycling,” Adam says, his wife settling warmly beside him on their large leather couch. Josh, in a navy golf shirt, sits on an ottoman. “I had to have surgery on my knee. Despite decades of practice, I’d never actually had to take any kind of painkiller stronger than ibuprofen.
“The first day after I was foggy, but by the second or third day I was really looking forward to my next dose. You’d think of all people I would have known what was happening, but it’s like it triggers something in you that short-circuits your logic and your knowledge. It’s like I knew what was happening and just didn’t care. I enjoyed the sense of well-being too much. And after all, I’m a doctor. I would know exactly my limits,” he snorts, self-derisively.
“Six months later and I was taking five Vicodin a day, and having to cover my tracks for some pretty shady tactics I was using to get them,” he says.
Adam considers himself lucky. It was his wife, not the state board or any controlling authority, that confronted him about his abuse of opioids. “She saved me,” he says. Adam checked himself into a high-end recovery clinic that specializes in helping medical professionals who have addiction issues. After a month, he says he was clean. But he still attends NA meetings twice a week with Joshua.
As a junior in college, Joshua fell into abusing Adderall, as many students do. The energy and focus he got from its use left him with powerful headaches that lasted days. His fraternity brothers came through for him, hooking him up with a steady supply of opioid pills.
“It didn’t take long for me to go from using them for headaches to using them for fun,” he says.
After Adam had returned from rehab, he told his family about his addiction. That’s when Joshua realized that if a man he so admired and was as strong as his father could succumb to addiction, then surely he had already.
“It was the hardest thing in the world to tell my dad, days after he was out of rehab, that I was addicted as well,” Joshua tells us. Joshua joined an out-patient program close to his parent’s home and that summer he too got clean.
“The thing is, and what makes me angry about it when I let it, is that through rehab and meetings, both my son and I are in recovery, but we will always be addicted. We’ll never be sure that we won’t ever have a moment of weakness again. We’ll have to always be on guard. And our worst fear is that some injury might befall one of us, and that we’ll have to face the possibility of needing pain medications,” Adam says. “Nothing can ever make us whole.”
**
Lawyers, Drugs, and Money
Want to know why political policies and solutions failed? Consider the following statistics from the Center for Public Integrity:
Drug companies and allied advocates spent more than $880 million on lobbying and political contributions at the state and federal level over the past decade; by comparison, a handful of groups advocating for opioid limits spent $4 million. The money covered a range of political activities important to the drug industry, including legislation and regulations related to opioids.
The opioid industry and its allies contributed to roughly 7,100 candidates for state-level offices.
The drug companies and allied groups have an army of lobbyists averaging 1,350 per year, covering all 50 state capitals.
The opioid lobby’s political spending adds up to more than eight times what the formidable gun lobby recorded for political activities during the same period.
For over a decade, a group called the Pain Care Forum has met with some of the highest-ranking health officials in the federal government, while quietly working to influence proposed regulations on opioids and promote legislation and reports on the problem of untreated pain. The group is coordinated by the chief lobbyist for Purdue Pharma, the maker of OxyContin.
Two of the drug industry’s most active allies, the American Cancer Society Cancer Action Network and the Academy of Integrative Pain Management, have contacted legislators and other officials about opioid measures in at least 18 states, even in some cases when cancer patients were specifically exempted from drug restrictions. State lawmakers often don’t know that these groups receive part of their funding from drug makers.
Five states have passed laws related to abuse-deterrent opioids and scores of bills have been introduced, with at least 21 using nearly identical language that some legislators said was supplied by pharmaceutical lobbyists. Pharmaceutical companies lobby for such laws, which typically require insurers and pharmacists to give preferential treatment to the patent-protected drugs, even though some experts say the deterrents are easily circumvented.
So it’s pretty obvious they’ve gamed the political remedy. Those politicians that Big Pharma haven’t bought outright, they’ve managed to hoodwink with concern troll-style doubletalk—helping to write the very rules and regulations that they want in the guise of fighting the opioid crisis and delivering better patient care. By spreading their tentacles around Washington, DC and state capitols across the country, Big Pharma has made it well-nigh impossible for any actual regulatory crackdown, or even oversight with any teeth.
Surely, then, the courts could offer a solution?
After all, as we noted in the previous chapter, there have been hundreds of cases brought against Big Pharma, with some measures of victory. But the victories, in terms of the dollar amounts, the damage to corporate reputation, and the imposition of judicial orders in lieu of regulatory crackdown, have been picayune. Ultimately they have slowed the pace of the opioid industry juggernaut about as much as bugs splatting on the windshield slows a tractor trailer on the highway.
In the latter half of the 2000s and into the 2010s, as the opioid epidemic consumed the American landscape, states and the US Department of Justice began the long slog of bringing lawsuits against Purdue Pharma and the Sacklers. The damage just couldn’t be ignored any more. A flood of lawsuits followed from municipalities and others. Eventually most of them were combined under a single umbrella in U.S. Bankruptcy Court.
And this is where it became a case “full of sound and fury, signifying nothing,” to quote Macbeth.
Because when you look at the big legal decision against Purdue Pharma that was announced in late August 2021, even as we were finishing this book, it became clear that there is no judicial will to bring justice against the perpetrators of this crime.
“Purdue Pharma Is Dissolved and Sacklers Pay $4.5 Billion to Settle Opioid Claims” reads The New York Times headline of September 1st, 2021.
“The ruling in bankruptcy court caps a long legal battle over the fate of a company accused of fueling the opioid epidemic and the family that owns it,” declares the secondary headline.
The news would appear grim for the Sackler tribe and Purdue Pharma, if the story were taken at face value.
Under the terms of the deal reached in U.S. Bankruptcy Court in White Plains, New York, Judge Robert Drain ruled that Purdue Pharma was dissolved as a corporate entity, and that the owners and the Sackler family would pay more than $4.5 billion in fines, fees and restitution. That money is supposed to be paid out throughout this decade, with the lion’s share coming from the former Purdue entity and from projected profits of the “public interest” drug company that will emerge from Purdue’s corpse.
The king is dead, long live the king, it seems. It is also a cruel twist that the new company will focus on making drugs to fight opioid addiction. First they sold America the disease, then they get to sell America the cure for that disease.
The details of the agreement and order provide that Purdue agreed to plead guilty in federal court to three counts of felony conspiracy to violate the Food, Drug and Cosmetic Act and the Federal Anti-Kickback Statute. The penalties under the deal include a $3.5 billion criminal fine and $2 billion in criminal forfeiture, the former of which is to be paid out in installments through 2030.
That’s it. That’s the extent of their criminal charges—violating business laws and regulations. And while Purdue must make public some thirty million documents, emails, and records that detail some elements of Purdue’s role in the opioid crisis, it won’t reveal the full extent of their malfeasance.
A few emails that have been made public in the course of the bankruptcy trial already are pretty damning, as reported by STAT News, with links to the full documents included.
In one email exchange dating back to January 1997, Purdue executives were hyper-concerned about Merck Medco, the national pharmacy benefit management firm, which was warning doctors that using OxyContin for chronic pain treatment could lead to addiction and abuse.
Richard Sackler told executives in the email chain that such concerns about addiction had to be “obliterated” as it threatened their move into the non-cancer pain management space:
I think that [Dr.] Paul [Goldenheim] has a good point, but we should consider that “addiction” may be a convenient way to “just say ‘NO’’’ and when this objection is obliterated, they will fall back on the question of cost. Unless we can give a convincing presentation that [Purdue’s] products are less prone to addiction potential, abuse or diversion than [other opioid] products. I think this can be done, but I defer to BK [Dr. Robert Kaiko] and RR [Dr. Robert Reder] and other experts.
In another email going back to 1996, the year OxyContin was brought to market, Sackler told executives that he wanted to highlight Purdue’s dogged willingness to fight any patent infringement by competitors so that the company would be “feared as a tiger with claws, teeth and balls.”
Another email exchange between Sackler and Michael Friedman, head of sales and marketing, came in 1997, where Friedman told Sackler that there was a false impression among physicians that OxyContin wasn’t as strong as morphine and that he didn’t want to correct that misperception because it was helping sales.
“It would be extremely dangerous at this early stage in the life of the product to make physicians think the drug is stronger or equal to morphine,” the email states. “We are well aware of the view held by many physicians that oxycodone is weaker than morphine. I do not plan to do anything about that,”
Sackler replied, “I agree with you.”
Despite all this obvious, criminal intent, none of the executives are facing jail time.
“Purdue deeply regrets and accepts responsibility for the misconduct detailed by the Department of Justice,” said Purdue Chairman Steve Miller, who joined the company leadership in July 2018, just before Purdue filed for bankruptcy.
As for the Sackler family? They are separately on the hook for—wait for it—just $225 million.
This for a family with a current estimated net worth of between $11 billion and $13 billion, which during these suits revealed they had personally moved $1.36 billion into offshore—and therefore untouchable—accounts, according to court records from this very same bankruptcy court, which Judge Drain specifically addressed in his ruling, according to The New York Times coverage of the judge’s decision. In fact, it’s suspected that the Sacklers transferred more than $10 billion out of the company between 2008 and 2017, as scrutiny of the company increased. Via The New York Times:“This is a bitter result,” he said. “B-I-T-T-E-R,” he spelled out, explaining that he was frustrated that so much Sackler money was parked in offshore accounts. He said he had expected and wished for a higher settlement.
Trey Garrison
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