Doctors detail how high-pressure drug marketing led to the opioid epidemic

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More than two dozen states, including Minnesota, are suing Purdue Pharma, the makers of the opioid painkiller OxyContin, for underplaying the addictive dangers of opioids while pushing them on patients who didn’t need them.

That deceptive marketing effort, the lawsuits claim, made Purdue (and other drug companies) billions of dollars, but also led to a nationwide opioid epidemic.

The tragic personal cost of the epidemic — more than 350,000 American lives since 1999 — has been enormous. The economic price tag has been huge as well. Government officials estimate that the opioid epidemic costs the U.S. economy $78.5 billion each year in medical care, lost productivity, addiction treatment and law-enforcement expenses.

In an essay published recently in the New England Journal of Medicine (NEJM), three doctors, including Dr. Scott Podolsky, a medical historian at Harvard University, offer a sobering reminder that the opioid epidemic was far from inevitable.

“The decision to allow marketers such wide scope to shape the circulation of potent and potentially dangerous drugs was just that — a decision,” they point out.

Things could have turned out differently if American policymakers and regulators had been willing to rein in the marketing excesses of the pharmaceutical industry.

Nothing new

As Podolsky says in an audio interview that accompanies the NEJM essay, those excesses started after the development of antibiotics in the 1940s, when American pharmaceutical firms quickly “figured out it was important to discover your own new drug, patient it and sell it.”

One man — psychiatrist Arthur Sackler, whose family now controls Purdue Pharma — was instrumental in revolutionizing drug marketing. Sackler perfected in the 1950s many of the promotional techniques commonly used by prescription drug companies today:  drug detailing (sending pharmaceutical company representatives to physicians’ offices to persuade them to use a particular drug), handing out free drug samples to physicians, giving physicians free food and drink and placing flashy drug advertisements in medical journals.

At the time, Sackler worked for Pfizer, a company long known for supplying chemicals to other companies, not for selling pharmaceuticals. That changed in 1950, when Pfizer developed the antibiotic Terramycin:

Under Sackler’s guidance, Pfizer increased its drug sales force from 8 “detail men” in 1947 to 2000 by 1950 (including, at one point, 70 medical students). Internal memos reveal that the marketing campaigns for Terramycin and, soon, Tetracyn (tetracycline) were conducted like military campaigns and described in the language of combat. Doctors in nearly every specialty were persuaded to consider conditions ranging from upper respiratory infections to urinary tract infections as necessitating antibiotics. The “prey” described in an internal Pfizer sales document from 1954 entitled “Easy Prey for Terramycin” referred not to the microbes Terramycin killed, but the prescribing physicians whose behavior could easily be swayed by marketing tactics.

These efforts were so successful that the use of antibiotics in the United States almost quintupled between 1950 and 1956, “setting in motion patterns of antibiotic overprescribing (and over-expectation) that contribute to antibiotic resistance and preventable adverse effects,” the doctors add.

Congress pushes back

Many people raised concerns about the aggressive marketing of medicines, and by the late 1950s, Congress, under the leadership of Sen. Estes Kefauver (D-TN), had begun to investigate Sackler and his techniques.

“The sketches [Kefauver and his staff] made of Sackler’s apparently vertically integrated empire — of drug companies, advertising staff, and medical journals — looked like components of a Mafia investigation,” Podolsky and his colleagues write.

Kefauver’s investigation (coupled with the thalidomide tragedy) led to passage of the 1962 Kefauver-Harris amendment to the Federal Food, Drug and Cosmetic Act, which strengthened the drug-approval process of the Food and Drug Administration.

But aggressive drug marketing continued.

More ‘prey’

In the mid 1990s, Purdue Pharma, which Arthur Sackler and his two psychiatrist brothers, Raymond and Mortimer, had purchased in 1952, launched its long-acting opioid OxyContin. Although Arthur was no longer alive (he died in 1987), the company continued — indeed, expanded on — the marketing techniques he had developed decades earlier.

“The company pioneered aggressive approaches to educating physicians about the use of opioids for noncancer pain, including [according to the lawsuits] the ongoing reformulation of pain as the ‘fifth vital sign’ and the ascribing of OxyContin addiction to specific problem patients, rather than to the drug itself,” write Podolsky and his colleagues. “Critically, Purdue saw physicians as easy prey for OxyContin, just as prescribers had been pretty for Terramycin.”

“The human toll of opioid overprescription now represents one of the largest iatrogenic epidemics in history,” they add.

Fixing a fundamental problem

Sadly, the situation hasn’t changed — and won’t until “a radical restructuring in this country of how physicians learn about new drugs” is initiated, Podolsky says in the audio interview.

“There’s $20 billion [a year] going into the medical marketing of physicians,” he notes — money that could be used “to evaluate drugs and educate physicians about those drugs” without all the current conflicts of interest.

That money could also be used to bring down the cost of prescription drugs.

“The parade of boom-bust cycles in pharmaceuticals (so inevitable that some see it as a kind of natural phenomenon, a ‘life cycle’) points to a more fundamental problem: the marriage of medical and marketing innovation that has become the defining feature of ‘modern’ pharmaceuticals,” Podolsky and his colleagues write in their essay.

“Perhaps it is time to rethink our approach to medical innovation itself and ask whether a marketing model is even the right means for promoting the value of new therapeutic products,” they add.

FMI: You’ll find the essay on NEJM’s website, although it’s behind a paywall.