There’s a new game that people play with television commercials: mute a pharmaceutical ad and guess what the drug treats. Erectile dysfunction (middle aged couple, arms around each other, walking the beach, sunset)? Depression (single middle aged woman, wrapped in an oversized sweater, walking the beach, cloudy day)? Fibromyalgia (more than middle aged woman, white, potting plants, grimace turns into smile)? Incontinence (more than middle aged woman, walking beach with male partner, picking up stray volleyball and throwing it back to kids, big smile)? In the heavily massmarketed world of prescription medications and people walking on the beach, I can’t tell you what an OxyContin user looks like. So how did OxyContin become so popular?
The answer is innovative, aggressive, very costly, criminally deceitful marketing.
In the brilliant article, “Poison Pill: How the American Opiate Epidemic Was Started By One Pharmaceutical Company,” Pacific Standard, February 23, 2015, (http://www.psmag.com/healthandbehavior/howtheamericanopiateepidemicwasstartedbyonepharmaceuticalcompany) Mike Mariani reports that Purdue Pharma, spent $200 million in 2001 alone to market OxyContin. The New York Times calls Purdue Pharma’s effort “the most aggressive marketing campaign ever undertaken by a pharmaceutical company for a narcotic painkiller.” ( http://www.nytimes.com/2007/05/10/business/11drugweb.html?_r=1&)
Mariani points out that “Purdue's multifaceted marketing campaign pushed OxyContin out of the niche offices of oncologists and pain specialists and into the primary care bazaar, where prescriptions for the drug could be handed out to millions upon millions of Americans.” The campaign to push OxyContin was indeed multifaceted. Here’s a brief sketch of the strategy:
1. Promote OxyContin for NonCancer Pain
Mariani reports that “beginning around 1980, one of the more significant trends in pain pharmacology was the increased use of opioids for chronic noncancer pain. Like other pharmaceutical companies, Purdue likely sought to capitalize on the abundant financial opportunities of this trend. The logic was simple: While the number of cancer patients was not likely to increase drastically from one year to the next, if a company could expand the indications for use of a particular drug, then it could boost sales exponentially without any real change in the country's health demography. This was indeed one of OxyContin’s greatest tactical successes.”
Art Van Zee, MD, in his comprehensive 2009 article “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” published in American Journal of Public Health , reports that “Purdue “aggressively” promoted the use of opioids for use in the “nonmalignant pain market. A much larger market than that for cancerrelated pain, the non–cancerrelated pain market constituted 86% of the total opioid market in 1999. Purdue's promotion of OxyContin for the treatment of non–cancerrelated pain contributed to a nearly tenfold increase in OxyContin prescriptions for this type of pain, from about 670,000 in 1997 to about 6.2 million in 2002, whereas prescriptions for cancerrelated pain increased about fourfold during that same period.”
2. Market to Physicians and Call It Education
Van Zee’s research found that “from 1996 to 2001, Purdue conducted more than 40 national painmanagement and speakertraining conferences at resorts in Florida, Arizona, and California. More than 5000 physicians, pharmacists, and nurses attended these allexpensespaid symposia, where they were recruited and trained for Purdue's national speaker bureau. It is well documented that this type of pharmaceutical company symposium influences physicians’ prescribing, even though the physicians who attend such symposia believe that such enticements do not alter their prescribing patterns.” Purdue threw in lots of logo’ed coffee mugs, pens, and ball caps as well.
3. Keep A Database
According to Van Zee, “one of the cornerstones of Purdue's marketing plan was the use of sophisticated marketing data to influence physicians’ prescribing. Drug companies compile prescriber profiles on individual physicians—detailing the prescribing patterns of physicians nationwide—in an effort to influence doctors’ prescribing habits. Through these profiles, a drug company can identify the highest and lowest prescribers of particular drugs in a single zip code, county, state, or the entire country. One of the critical foundations of Purdue's marketing plan for OxyContin was to target the physicians who were the highest prescribers for opioids across the country. The resulting database would help identify physicians with large numbers of chronicpain patients.” Van Zee also reports that, “Unfortunately, this same database would also identify which physicians were simply the most frequent prescribers of opioids and, in some cases, the least discriminate prescribers.”
4. Sales Rep Bonuses
Van Zee’s research also found that “a lucrative bonus system encouraged sales representatives to increase sales of OxyContin in their territories, resulting in a large number of visits to physicians with high rates of opioid prescriptions, as well as a multifaceted information campaign aimed at them. In 2001, in addition to the average sales representative's annual salary of $55 000...Purdue paid $40 million in sales incentive bonuses to its sales representatives that year.”
5. Target Primary Care Practitioners
The New York Times reports that “Purdue Pharma heavily promoted OxyContin to doctors like general practitioners, who had often had little training in the treatment of serious pain or in recognizing signs of drug abuse in patients.” (I added the bold in this section.) Van Zee reports that “Purdue promoted among primary care physicians a more liberal use of opioids...by 2003, nearly half of all physicians prescribing OxyContin were primary care physicians. Some experts were concerned that primary care physicians were not sufficiently trained in pain management or addiction issues. Primary care physicians, particularly in a managed care environment of time constraints, also had the least amount of time for evaluation and followup of patients with complicated chronic pain.“ Mariani makes the claim that by “Combining the physician database with its expanded marketing, it would become one of Purdue's preeminent missions to make primary care doctors less judiciouswhen it came to handing out OxyContin prescriptions.”
6. Offer “Starter” Coupons
While it’s not uncommon for pharmaceutical sales reps to provide physicians with an abundance of “sample” drugs, Purdue took the sample strategy even further, providing consumers, through physicians, with starter coupons good for anywhere from a seven to 30 day supply of free OxyContin. While a 30 day supply of any narcotic might raise concerns about developing drug dependence, OxyContin was promoted to doctors, and by extension patients, as a “safe” opioid.
7. Minimize Risk of Addiction
Mariani writes that right from its launch, Purdue set out to distinguish OxyContin from its competition. “The cornerstone of its marketing campaign was the drug's incredibly low risk of addiction, an enviable characteristic made possible by its patented timerelease formula. Through an array of promotional materials, including literature, brochures, videotapes, and Web content, Purdue proudly asserted that the potential for addiction was very small, at one point stating it to be "less than 1%.”” Sales representatives told some doctors that the drug didn't even produce a buzz, according to USA Today.
The New York TImes reports that “Among other things, company sales officials were allowed to draw their own fake scientific charts, which they then distributed to doctors, to support that misleading abuserelated claim.” Van Zee reports that Purdue “trained its sales representatives to carry the message that the risk of addiction was “less than one percent.” and that “a consistent feature in the promotion and marketing of OxyContin was a systematic effort to minimize the risk of addiction in the use of opioids for the treatment of chronic non–cancerrelated pain.” He goes on to explain that while research has established that 3% to 16% of the general population will experience some form of addiction within their lifetime, no credible study had determined the rate of “iatrogenic” addiction occurring during longterm opioid use for noncancer pain. “Iatrogenic” means “caused by medical treatment,” in this context, presumably as opposed to “caused by recreational use of illegal drugs.”
8. Hope the FDA Is Both Gullible and Cooperative
Mariani writes that “The timerelease conceit even worked on the FDA, which stated that "Delayed absorption, as provided by OxyContin tablets is believed to reduce the abuse liability of a drug." Armed with the timerelease formula and misleading statistics about the risk of addiction, Purdue positioned the drug as a relatively safe choice.”
The New York Times reports that “when the painkiller was first approved, F.D.A. officials allowed Purdue Pharma to state that the timerelease of a narcotic like OxyContin “is believed to reduce” its potential to be abused.”
Van Zee reports that “When OxyContin entered the market in 1996, the FDA approved its original label, which stated that iatrogenic addiction was “very rare” if opioids were legitimately used in the management of pain.” But then, in July 2001, “to reflect the available scientific evidence, the label was modified to state that data were not available for establishing the true incidence of addiction in chronicpain patients.” Iatrogenic means “caused by medical treatment.” Presumably, in this context, iatrogenic addiction differs from “caused by recreational or illegal use” addiction.
In 2007, in one of the largest federal criminal and civil cases ever against a drug company, Purdue Frederick Company, the parent of Purdue Pharma, pled guilty to and was fined $600 million for felony “misbranding” OxyContin. “Misbranding” is a broad statute that makes it a crime to mislabel a drug, fraudulently promote it or market it for an unapproved use. At the same time, three Purdue executives individually pled guilty to misbranding and were fined a total of $34.5 million. Announcing the federal verdict in 2007, The New York Times reported that “Purdue Pharma acknowledged in the court proceeding today that “with the intent to defraud or mislead,” it marketed and promoted OxyContin as a drug that was less addictive, less subject to abuse and less likely to cause other narcotic side effects than other pain medications.”
Similar cases against Purdue Pharma most notably in Kentucky are slowly winding their way through the court system.
The marketing strategy of Purdue Pharma relied heavily on systemic vulnerabilities. The FDA is understaffed and underfunded, and it cannot possibly keep up with its responsibility for the review and approval of pharmaceutical marketing materials. Many primary care physicians lack the specific training to monitor patients for addiction, and the managed care system squeezes the time and attention of even the most devoted healthcare providers. Sophisticated incentives and Big Brotherlike databases subliminally sway and influence prescribing habits, and criminally deceptive marketing materials promise physicians an opportunity to ease suffering a promise that preys on the very organic, benevolent motivations of healers.
OxyContin has made its way to the streets, and addiction has made its way into so many lives. Parents fight to accept powerlessness while at the same time fighting the cruel stigma attached to addiction. Stigma? Really? Where is the outrage? Where is the public awareness of and objection to evil, corporate, greed based manipulation of our entire healthcare system? Where is the compassion for prescribing physicians made complicit in an astonishing fraud that harmed rather than healed? We might all be more awake if we weren’t so massmarketed into a good night’s sleep, courtesy of Big Pharma.
Reprinted with permission from www.whenweloveanaddict.com. Copyright 2015 Kay Ryan