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Barry Meier is a former reporter with The New York Times who was part of the team that won the 2017 Pulitzer Prize for International Reporting, and the author of Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic, a new paperback edition of which was just released. A six-part series inspired by Pain Killer will be streaming on Netflix in August.

More than two decades ago, in 2001, I wrote my first article for The New York Times about the misuse and abuse of OxyContin. That reporting evolved into a 2003 book titled Pain Killer, which described how Purdue Pharma, the maker of OxyContin, used illegal methods to promote the drug, and how the company and its allies distorted science to convince doctors that strong narcotics called opioids were safe. The book also traced the history of how the pharmaceutical industry had co-opted the medical community using promotional techniques pioneered by Dr. Arthur Sackler, whose incredibly wealthy family owned Purdue.

At the time, I thought Pain Killer might sound an alarm. That was naive.

Over the next 20 years, opioid prescriptions skyrocketed, and some 225,000 people died in the United States and Canada from overdoses involving OxyContin and other prescription painkillers. Today, an even deadlier product, counterfeit fentanyl, accounts for most overdose deaths. But while illegal fentanyl is made and sold by criminal cartels, medications such as OxyContin are produced by pharmaceutical companies and legally prescribed by doctors. Opioid use in the U.S., which peaked in 2012 at an astounding 255 million prescriptions, has steadily declined since then – but even in 2020, opioid prescribing in some areas was nine times higher than others, according to the Centers for Disease Control.

I’ve often wondered how a public-health crisis that could have been contained instead turned into an inferno. It would be easy to blame all the broken lives on the Sacklers, who continue to insist they did nothing wrong – but that would be too simple. An army of allies and enablers also planted seeds that turned OxyContin into the gateway drug of the opioid epidemic. Some of them were ideologues bent on changing medical history; some of them were well-intentioned physicians who just wanted to do their best for patients.

This was compounded by companies and some professionals acting in appalling ways. Opioid manufacturers dumped hundreds of millions of pain pills in the U.S. and Canada. Doctors operated “pill mills,” dispensing opioid prescriptions for cash. Pharmacies turned a blind eye to the mobs of customers lining up outside their doors. Those entrusted with protecting the public – lawmakers, regulators and bureaucrats – failed to take steps to blunt the epidemic’s trajectory.

As the opioid epidemic accelerated, lawyers, consultants and spin doctors also rushed in to make fortunes protecting Purdue and other opioid producers. Chief among them was McKinsey & Co., the world’s most prestigious consulting firm. As recently as 2014, according to The Globe and Mail, McKinsey offered Purdue Pharma Canada a plan to boost opioid sales. And while the Canadian branch didn’t take the consultants up on it, that may have made little difference: McKinsey was still doing banner business advising executives at Purdue’s main headquarters in Stamford, Conn. Court papers alleged that these projects included techniques to “turbocharge” OxyContin sales, and a campaign to “counter the emotional messages from mothers with teenagers” who overdosed on OxyContin. (In 2021, McKinsey, while denying wrongdoing, paid US$600-million to settle claims brought against the firm by dozens of states and others.)

Why did people, from doctors to consultants, continue to push OxyContin, despite the decade-plus of information and reporting that had emerged about its dangers? What kind of dissonance had to exist, to allow this ethical quagmire to persist even as the opioid crisis grew and grew? The reason may appear simple – Purdue’s deep pockets created monetary incentives – and certainly, that was a factor. But a more complicated reason was the power of ideology, driven by a compelling narrative.

There is no question that OxyContin, which contains oxycodone, a long-used opioid, is a useful medication, and that its benefits can outweigh its risks for some patients, such as those with cancer or conditions accompanied by severe chronic pain. But to create a blockbuster product, Purdue needed to craft a narrative to convince doctors to prescribe a high-powered narcotic for back pain, dental pain, sports injuries and other common, less serious conditions.

And so Purdue launched a massive marketing campaign for OxyContin after it was introduced in 1996, resting on a simple claim: that the drug would be less prone to abuse than shorter-acting pain pills such as Percocet, because it was formulated as a long-acting, time-release narcotic.

One might think the U.S. Food and Drug Administration would require Purdue to submit rigorous evidence to prove this. Instead, in an extraordinary blunder, the agency accepted Purdue’s theory that drug abusers – drawn to the quick kick of standard pain pills – would avoid OxyContin because of how slowly it said the narcotic entered the bloodstream.

By 2001, when I started reporting about OxyContin, the drug was generating more than US$1-billion in sales for Purdue and the Sacklers. But Purdue’s theory had also fallen apart. Teenagers, drug abusers and others found it was easy to overcome the pill’s time-release coating and get access to the huge trove of pure oxycodone it contained. Addiction to the drug was spreading and the body count was starting to mount.

But Purdue’s narrative didn’t implode in the medical community, and doctors kept writing OxyContin prescriptions. As it turns out, that’s because the company was hiding critical information from doctors – including a Canadian study that could have stopped the company’s marketing campaign in its tracks.

In 1998, just as physicians were beginning to prescribe OxyContin, a little-noticed study appeared in the Canadian Medical Association Journal. In it, a team of researchers from the University of British Columbia reported an unexpected discovery while investigating which prescription medications commanded the highest prices from drug abusers in Vancouver. The hottest drug on the street, it turned out, was an older, morphine-deploying painkiller made by Purdue called MS Contin: a long-acting, time-release opioid similar in formulation to OxyContin. It was being abused, the report said, because the time-release coating of the pill could be easily defeated.

Some people did notice the study, including an assistant professor in the University of Toronto’s department of family and community medicine named Brian Goldman, who warned in an editorial that accompanied the Vancouver study that it should “ring warning bells” about safety claims for OxyContin. But Purdue treated the report like any information that threatened profits; it ignored the study and never distributed it to regulators and physicians. Dr. Goldman, who would go on to become a popular CBC radio personality, also didn’t miss a beat: By 1998, he had already received Purdue funding for workshops and training events, and for years, he continued to urge other doctors to prescribe OxyContin and similar opioids while receiving money from the company.

In 2012, more than a decade later, he wrote another editorial about OxyContin – this time in this newspaper, discussing his role as a Purdue consultant and the allure of drug-industry money. “I wanted to help teach doctors who were getting very little training in pain management and to help patients who were in pain. I never underplayed the risk of addiction, always urging colleagues to carefully assess patients and to make certain other remedies had been tried first,” he wrote in The Globe and Mail.

He also acknowledged that drug-industry money could distort medicine. “I no longer believe it to be possible for educational courses paid for by drug companies to be free of corporate bias,” he wrote. “I see a culture of indifference to the influence pharmaceutical money has on many of us.” Left unsaid: Why did it take him so long to have this awakening? By 2012, more than 100,000 people had died from overdoses involving OxyContin and other opioids. (Dr. Goldman did not respond to requests for comment for this article.)

In that same op-ed, Dr. Goldman also inadvertently illuminated another reason why some physicians ignored the chaos spreading around them. We tend to think of money as the main corrupting influence, but for some, there was an even more powerful force: the grip of ideology.

In the 1990s, hundreds of well-intentioned doctors became foot soldiers in a medical movement known as the “War on Pain.” The initiative was based on a compassionate idea – namely, that doctors, because of overblown fears about the addictive risks of narcotics, were withholding these drugs from patients and thus causing them to suffer. The movement’s ideological leader was a pain specialist in New York, Dr. Russell Portenoy, who practised at Memorial Sloan Kettering hospital, a high-profile cancer treatment centre. He wanted to convince physicians that high dosages of opioids such as OxyContin also could be used in patients experiencing pain from causes other than cancer.

The trouble was Dr. Portenoy didn’t have much evidence. Instead, he claimed that three studies had found that powerful opioids could be used safely “for a long time with few side effects, and that addiction and abuse are not a problem,” as he told The New York Times in 1993. Those studies became central to the “War on Pain” and the basis for Purdue’s claim that long-acting opioids such as OxyContin posed an addiction risk to patients of “less than 1 per cent.”

But in the early 2000s, I located those obscure reports, and it was clear to me even as a layman that Dr. Portenoy had cherry-picked data from them and misrepresented their findings, which didn’t contain a shred of evidence about long-term opioid use. One of these supposed studies wasn’t even a study, but a letter to a medical journal. Another was an actual clinical trial involving patients with migraine headaches, but it urged doctors not to use opioids to treat the condition because there was a danger of dependency and abuse among patients with chronic headaches.

Doctors never took the time to read the reports, however, and in the 2010s, even as the opioid epidemic intensified, their supposed findings were repeated hundreds of times in medical journals and the popular press. Long afterward, Dr. Portenoy grudgingly acknowledged to me that he had used the studies to create a narrative to advance his agenda. But he and other physicians, having wedded their careers and reputations to an ideology, found it hard to let go. In a 2012 interview with The Wall Street Journal, even as Dr. Portenoy acknowledged that his teaching “reflected misinformation,” he pushed back by citing his mother’s use of hydrocodone for her arthritis: “If you insist on regulation, then you’re consigning my mother and many millions of people like my mother to live in chronic pain.”

There was another reason why doctors continued prescribing strong opioids in the face of mounting death tolls. It involved another myth, one created by Purdue and its fellow travellers. They divided the world into two distinct groups: “good” people, or patients who only benefited from opioids, and “bad” people, or abusers whose behaviour jeopardized patients. Dr. Richard Sackler, who was Purdue’s president during its marketing tsunami for OxyContin, best captured this toxic mindset in a now-infamous e-mail: “We have to hammer on the abusers in every possible way,” he wrote in 2001. “They are the culprits and the problem.”

Both pain patients and those addicted to drugs deserve high-quality care. But by casting the opioid epidemic as a war between good and evil, Purdue and its allies blinded doctors to another toll exacted by overuse of OxyContin and opioids: While some patients benefited from the drugs, others paid a terrible price. Strong narcotics, particularly if used at high dosages and over long periods of time, carry an array of serious side effects, including emotional dependency on drugs, reduced sex drive, lethargy and even increased sensitivity to pain. Some patients don’t want to get off the opioids, and seek other methods of treating their pain. “Addiction is not the real problem,” a former champion of high-dose opioid use, Dr. Scott Fishman, once told me. “What we didn’t realize is that patients would use these drugs to opt out of life.”

Earlier this year, the saga of OxyContin and the Sacklers approached its conclusion in a courtroom. An appeals court in the U.S. approved a plan under which the Sacklers will contribute US$6-billion to the bankruptcy of Purdue Pharma; in return, the family will receive lifetime protection from future lawsuits. That agreement has proceeded, despite congressional efforts to prevent such a bargain.

I’ve been asked what I think of the deal, and my response is simple. It’s great that so much money is going to drug addiction treatment; it’s extraordinary that the Sacklers were able to buy themselves an insurance policy.

The story of OxyContin and the Sacklers appears to be ending, with the family’s name in tatters. But the forces that set it into motion are still in play. Companies with drugs or devices with benefits that appear to outweigh their risks for a small pool of patients still work to cash in by marketing the product to as many patients as possible. There are still doctors who are eager to make money or a name for themselves by jumping on board. Regulators, lawmakers and insurers still look the other way too often. The kindling is still all around us. An inferno can still erupt.

These are factors and forces that existed long before OxyContin, and that situation will happen again and again – at least until people who know better stand up, speak out and don’t stop screaming.

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