The Responsibility for and Obligation to Fix the Opioid Epidemic Lies with Purdue Pharmaceuticals and the Healthcare Sector

The opioid epidemic is a complex crisis, and many factors contribute to this uniquely American dilemma. However, certain players hold more responsibility than others in contributing to this problem and failing to address it. In his book, Dreamland, journalist Sam Quinones tells the tale of the opioid epidemic through the stories of various players, from drug traffickers from Mexico, to pharmaceutical companies, to the medical system, and opiate users themselves. However, Quinones demonstrates that despite the multifactorial nature of America’s problem, the heart of the responsibility lies with the medical field. From greedy pharmaceutical companies and selfish doctors to many more well-meaning but complacent physicians, the American medical complex enabled this crisis and failed to intervene. This group is most culpable because the medical system is obligated to protect the health of the American people, yet it was a player in significant suffering and death.

Opioids take many forms, but heroin is notoriously a killer. Given this, it is reasonable to blame the heroin providers for the opioid epidemic. However, this approach neglects the complicated history of medicinal opiate prescribing that primed the nation for heroin abuse. As Quinones epitomizes this history, “heroin entered the mainstream via pills” (Quinones 7). Various actors in the medical system readied the country for addiction, but none pushed opiates like the pharmaceutical industry. People have used opiates for medicinal and non-medicinal purposes for hundreds of years, and addiction is not a new phenomenon. However, the current crisis is unmatched in its magnitude because it began when Purdue Pharmaceuticals employed frankly evil tactics to profit off of a new opioid preparation. Purdue’s unethical marketing catapulted the US into an era of addiction.

Purdue released OxyContin, a time-release formulation of oxycodone, in 1996 and employed a calculated marketing campaign that made its pills so pervasive and primed the country for opiate addiction (Quinones 124). Years before, Pfizer’s Arthur Sackler revolutionized pharmaceutical advertising when he demonstrated that intense advertising campaigns directed at doctors led to significant profits (Quinones 31). Purdue took the modern pharmaceutical advertising system to a new level with OxyContin. Not only did they send shiny, colored ads directly to physicians, but they tasked thousands of salespeople to butter up doctors with gifts and the promise that OxyContin was the next big thing (Quinones 30). The company was relentless, increasing its sales representatives almost threefold in 10 years after the rollout of OxyContin and rewarding salespeople who sold the most drugs (Quinones 133). Salespeople gave doctors coupons for their patients’ free first prescription of OxyContin (Quinones 134). Purdue also enticed physicians with travel, meals, and amenities when they funded continuing medical education (CME) seminars as an opportunity to boast of their new drug’s supposed ability (Quinones 135). They caught the ear of doctors who were softened to the company by the gifts and special treatment they received. The company also distributed marketing videos to thousands of doctors before the FDA approved them, violating the administration’s regulations (Quinones 136). Purdue also founded pain societies, such as the American Pain Foundation, that advocated for their drugs (Quinones 137). The pharmaceutical company used a variety of tactics to not only inform doctors of OxyContin but lure them into preferentially prescribing it. It was not until the drug had been on the market for six years that the US Department of Health and Human Services barred pharmaceutical companies from using these inappropriate methods (Quinones 133).

Purdue was problematic not just in its methods of marketing OxyContin but the content of those advertisements. Without much evidence to back their claims, Purdue representatives bragged about the drug’s safety. Salespeople insisted that the unique 12-hour time-release formula made their drug less addictive because it did not create intense highs and lows (the cycles of euphoria and depression) that make opiates so addictive (Quinones 125). The company even convinced the FDA to label the drug with a claim of its lower abuse potential than other opioids (Quinones 126). Quinones found that company executives constantly fed salespeople the information that OxyContin was non-addictive, which became the “cornerstone of marketing of the drug” (Quinones 126, 265). Ultimately, Purdue marketed OxyContin as a risk-free solution to any and all pain, and doctors latched onto this claim (Quinones 127). Purdue was massively successful using these strategically misleading claims and relentless marketing tactics; OxyContin sales rose from 670,000 in 1997 to over 6 million in 2002 (Quinones 138). The pill was eventually 90% of the company’s revenue (Quinones 138).

The content of Purdue’s advertisements was misleading, and the company knew that; Purdue actively suppressed any evidence to the contrary that their drug was non-addictive. Eventually, researchers found that the company’s data on blood drug levels that supported the claim that OxyContin was non-addictive was incorrect and falsely exaggerated (Quinones 265). They threatened suit against people beginning to recognize that OxyContin was addictive, and company lawyers got early lawsuits dropped (Quinones 146, 201). When a 2001 British study demonstrated patients experiencing withdrawal from OxyContin, Purdue took a plea deal and neglected to make the findings known (Quinones 267). After lawsuits in the late 2000s that revealed Purdue knowingly misbranded OxyContin as less addictive, in 2010, the company added an abuse-deterrent to the pill, making it harder to inject (Quinones 304). They had the capability to do this yet failed to do so when they first marketed the drug in 1996. Purdue was undoubtedly aware that its claims about OxyContin were false, yet it marketed the drug as non-addictive in order to make a profit. The company manipulated doctors and patients, making money without caring about the consequences. Thus, much of the responsibility for the opiate crisis in the US lies with Purdue as it set the stage for overprescribing opioids, and its drug “served as a bridge between mild opiate painkillers and heroin” (Quinones 191).

The entire population of medical providers in the US also shares the responsibility for the opioid epidemic. Quinones argues that while it is true that doctors were in many ways manipulated by Purdue, they were not passive actors themselves. Several prominent physicians took advantage of their patients by perpetually prescribing opiates to profit from patient visits. David Procter is the most well-known of the “bad doctors” as he was one of the first to transform pain clinics into profit centers. Procter prescribed copious amounts of opioids even to patients without a diagnosis (Quinones 25). He was known in his community for being quick to write a prescription, asserting that the patient was always right regarding pain (Quinones 25). His aggressive prescribing was profitable; while he did not make money when a patient filled a prescription, he got their co-pays for each visit. Quinones describes how his business flourished as new patients heard of his reputation, and repeat customers kept coming back for refills (Quinones 25). Procter trained other providers and advised other local doctors on his business model, and these providers expanded the “pill mill” to other towns (Quinones 58). Pain clinics popped up across the nation under a business model of prescribing to keep a patient, and their monthly fee, or copay, coming back (Quinones 159). The business attracted unethical doctors looking to make a profit without acknowledging the risk of getting their patients hooked on narcotics.

Although these “bad doctors” certainly had an impact, the opioid crisis would not be so widespread if not for the mistakes of the medical community at large. It is important to note that in addition to immoral doctors who disregarded the best interest of their patients to make a profit, there were many well-meaning doctors who failed to question their role in the crisis and prescribed opioids at alarming rates. Quinones demonstrates that despite the good intentions of most physicians, the crisis would not be so widespread if not for their complacency. The problem stems from the years preceding OxyContin, as the medical community grew more willing to prescribe opiates for chronic, non-terminal pain (Quinones 124). The greater acceptance of opiates grew from a movement that asserted that pain was a crisis in America (Quinones 92). Many prominent organizations asserted that pain was an undertreated phenomenon. For instance, the World Health Organization claimed that freedom from pain is a universal human right and asserted that doctors should believe patients who claim they are suffering (Quinones 82). The American Pain Society (APS) announced that pain was the “fifth vital sign,” and in 1998, the Veterans Health Administration endorsed this (Quinones 94, 95). From the 1980s on, doctors elicited a focused pain history from their patients and asked them to quantify their pain on a 0-10 (Quinones 97). As the medical community grew alarmed at the “epidemic of pain,” Quinones argues that there was a “revolution in thought and practice” that not only permitted but encouraged doctors to prescribe more and more pain medication (Quinones 95). Hospital lawyers cautioned doctors about potentially facing a lawsuit if they failed to prescribe narcotics for pain patients and legislators passed laws exempting doctors providing opioids for pain from prosecution (Quinones 95, 137). The cultural shift in acceptance of pain management made physicians feel obligated to use novel pharmaceuticals to treat pain (Quinones 125).

The shifting culture of the patient always being right about their pain coincided with misinformation and lack of knowledge about opiates. Most physicians were unaware of the long-term effects of opiate treatment for pain and the potential consequences. At this time, the medical community accepted that opiates were addictive if taken inappropriately, but they were considered safe for people in genuine pain. However, there was a notable lack of research supporting this (Quinones 98). There were a few small papers that asserted a low likelihood of addiction in patients treated with opiates for pain, but many of these results were extrapolated and misinterpreted. For instance, Quinones argues that a one-paragraph letter to the editor featured in the New England Journal of Medicine in 1980 by Dr. Hershel Jick and his graduate student Jane Porter is one of the most cited yet misinterpreted papers on this issue (Quinones 110). The paragraph entitled “Addiction Rare in Patients Treated with Narcotics'' was an analysis based on 12,000 hospital-treated patients using opiates whose results claimed that only four patients became addicted to narcotics, and this “less than 1%” statistic stuck (Quinones 15, 107). Porter and Jick’s analysis was accurate but lacking in many ways. The study neglected variables such as how often or for how long the patients took opioids and what doses they took, and the sample only included hospitalized patients whose access to opiates was controlled and overseen by doctors (Quinones 16). Pain specialist Nathaniel Katz states, “Porter and Jick is amazing for the lack of information in it, but that paragraph gives you relief from your inner conflict. It’s like drinking from the breast. All of the sudden comfort washes over you” (Quinones 315). Quinones argues that the medical community “took it as gospel” because the paper’s claims felt right; “if you have pain, you can't get addicted to opiates because pain soaks up the euphoria” seems logical (Quinones 107, 188). While Porter and Jick were not malicious in their intentions, their paper added to the discourse that opiates were safe for pain patients. This, combined with Purdue’s claims that OxyContin was non-addictive, created the notion that opiates were safe for pain. This idea became pervasive and unquestioned. The medical community as a whole did not do the issue justice. It took the current research as an irrevocable fact rather than questioning and further investigating it as is good scientific and medical practice.

Given the pressures to prescribe opiates and the assertion that they were non-addictive in pain patients, many well-meaning doctors latched onto the trend of prescribing (Quinones 154). Although they meant no harm, they were complicit in causing this crisis. Many doctors kept increasing a patient's opiate dose, even if it did not relieve their pain (Quinones 110, 233). This is contrary to the practice of medicine in so many ways; usually, when a treatment fails, doctors do not increase the dose of a medication indefinitely but instead try a new modality. It is essential to acknowledge how system-based factors in the disjointed US healthcare system made it difficult for doctors to go against the tide of opiates. Doctors often feel where an individual doctor often feels powerless to change as they are trapped in a system that undervalues them and their time. During the rise of OxyContin, insurance companies began to negotiate lower fees with doctors for treatment and reduced the services they would cover (Quinones 97).

As a result, doctors had to see more patients per day to maintain their income. Having less time with each patient meant that many doctors did not have the hours in a day to deal with chronic pain patients appropriately (Quinones 97). Doctors, especially the majority of primary care physicians with little training in pain management, saw these patients as a time drain, one even saying, “one chronic pain patient can ruin your whole day” (Quinones 108). Throwing pills at a patient made these visits easier; research shows that as doctor's visits shortened, opiate prescribing rose in parallel (Quinones 108). Well-meaning doctors were confined within a system that pushed them to prescribe opiates even though research established that a multidisciplinary approach to pain was optimal. However, prescribing opiates allowed doctors to deal with pain much faster, and many insurance companies only reimburse for meditations, not other pain therapies (Quinones 124). These various systemic pressures pushed doctors to prescribe opioids at high rates. However, every doctor prescribing these pills is responsible for contributing to the crisis.

Another way the healthcare system is ultimately responsible for the opioid crisis is the failure to track deaths related to opiates and create a prescription monitoring system (Quinones 241). This led to a delay in the realization that opiates were causing addiction and death, which proved to be detrimental. It was several years before trends showing increasing opioid overdose deaths were recognized. Autopsy data on overdose was hard to come by because each physician documented opiate deaths differently, and initial rises in death were attributed broadly to “poisoning” (Quinones 119, 248). It took even more time to realize that there was a relationship between dispensed opioids and overdose deaths (Quinones 252). The actions of the medical community, from good doctors to greedy pharmaceutical companies, set the country up for the opioid crisis and the wave of heroin abuse that followed. The actions of dishonest individuals but also well-meaning doctors functioning in a system working against them created the optimal environment for opioid prescription. The drug became the fastest selling in the US, and the country far outpaced all others in sales (Quinones 190). By the time the medical community opened its eyes to the dangers of using opiates for pain, the damage had been done (Quinones 304). Quinones argues that the opioid crisis was deeply rooted in American society long before heroin even took hold, and this was primarily the responsibility of the healthcare sector.

Quinones juxtaposes the story of Purdue with the story of the suppliers of heroin– the Xalisco boys from a small community in Mexico. In doing so, he demonstrates how drastically different the motivations of each group were. While Purdue’s contributions to the opioid epidemic were based on greed, the Xalisco boys participated out of desperation (Quinones 165). Additionally, they did not have the same responsibility of protecting Americans that the healthcare system bears. While the Xalisco boys and “The Man'' behind them are not absolved of their role in the crisis, they bear less responsibility than the sector obligated to protect Americans' health.

Quinones argues that if Purdue did not prime the US for opiate addiction with OxyContin, the Xalisco traffickers would not have had such an impact. He describes how Xalisco boys were successful because oxycontin had already “tenderized the terrain” (Quinones 165). Many Americans were already addicted to opioids when heroin arrived and switched to the Xalisco suppliers because their product was cheaper (Quinones 166). Data shows that 80% of heroin users had used a prescription painkiller first (Quinones 192). While the Xalisco traffickers were looking to exploit addicts to make a profit, they did this out of desperation. People in Xalisco knew they could have a better life if they sold heroin; they were poor and circumstantial pressure led them to the US seeking opportunity (Quinones 259). The Xalisco boys used their money to buy clothes and houses for their families back in Mexico, not to live lavish lifestyles as the Purdue executives did (Quinones 261). Opioid users themselves recognized that the Xalisco boys were not cold-blooded killers, just men looking for opportunity. One user said, “they were nice guys, clean cut, not killers, just working-class boys trying to get ahead and were probably living back in Mexico somewhere” (Quinones 322). Quinones argues that they were “not career thugs, they were farm boys hoping for a better day through black tar” (Quinones 229).

That is not to say that the Xalisco boys are absolved of all responsibility. Many of the traffickers were far from innocent and knew the consequences of selling their drugs. Furthermore, they were relentless in their tactics, lurking near methadone clinics in search of addicts, being on call 24/7, and giving free samples (Quinones 65, 230). Nevertheless, this group bears less responsibility for the opioid epidemic because heroin only took hold because opiates arrived first (Quinones 305). Additionally, drug traffickers profited much less than the pharmaceutical companies and were motivated by desperation rather than greed (Quinones 305). Quinones also alludes that although the Xalisco boys were the first to “recognize and systematically exploit the new market for joining that the overprescribing of narcotic pills was creating,” they would not be the last (Quinones 347). Other groups saw the opportunity, too. Had it not been for the Xalisco boys, another group would likely have stepped into that role. Furthermore, the only reason the heroin from Mexico had the impact that it did was because pharmaceutical companies and the healthcare system primed the country for addiction. Had this not occurred, heroin would likely not have had the expansive toll it did. As Dr. Philip Prior states, “I've yet to find one who didn't start with oxycontin. They wouldn't be selling this quantity of heroin on the streets right now if they hadn’t made these decisions in the boardroom” (Quinones 269).

Another group that Quinones exempts as the primary group responsible for the opioid crisis is the users themselves. It is easy and seems logical to blame the users because the most proximal cause of heroin death is their decision to abuse the substance. Since the dawn of opiate use, users were demonized as deviant addicts, criminals whose use was because of a moral failing (Quinones 299). However, modern neuroscientific research demonstrates the control that opiate molecules exert. In his chapter entitled “The Molecule,” Quinones describes how a person becomes a slave to opiates because “the morphine molecule exerts an analogous brainwashing on humans, pushing them to act contrary to their self-interest in pursuit of the molecule” (Quinones 39). Since addiction is a brain-altering disease, addicts cannot be at fault. Although people addicted to opiates may not be entirely innocent, they are not entirely responsible for their addiction or the country’s opioid crisis. Just one mistake can lead to a mind-altering addiction that destroys or takes one’s life forever. Addicts find themselves in a system that pushes them towards a path and fails to help them, even when they want to get off that beaten road.

As with any other problem, it is reasonable that those responsible for the opiate epidemic should make amends. As Quinones demonstrates, the most significant players are the pharmaceutical companies and the medical system, and these groups have the power and obligation to remedy their wrongs. Addressing this crisis will require a multidisciplinary and expansive approach that will cost millions of dollars. The medical community, from pharmaceutical companies to physicians, must contribute in numerous ways.

First, drug companies must pay for their transgressions. While they do not have the expertise to help those struggling, they can certainly provide funds to support programs. Efforts by the medical community to help users will be costly, but Purdue should contribute the funds needed. OxyContin was Purdue’s most profitable drug because of its relentless and false advertising, so it is reasonable for the company to pay. Purdue and other pharmaceutical companies also must be transparent and ethical in all future marketing. The practices they used to promote OxyContin were entirely inappropriate, and they must refrain from creating another disaster in the future.

Medical providers can ameliorate this opioid crisis in two ways; by preventing more people from becoming addicted to opioids and by helping those who are already addicted. Now that the consequences of indiscriminate opioid use are apparent, doctors should adjust their approach to prescribing the drugs. In recent years, the government implemented measures to monitor opiate prescribing, which led to doctors being more reluctant to prescribe opioids and dramatically cutting the amount they give patients when they do. However, this made it difficult for many patients needing low-dose opiate treatment for pain to find it (Quinones 306). Physicians should address this lack of nuance and be willing to look past an all-or-none approach and prescribe opiates when appropriate. This will need to be addressed early in their education, from medical school through continuing medical education throughout their careers. Doctors need to be informed about how their prescribing habits can affect patients’ lives, and a one-time seminar on the opioid epidemic in medical school is insufficient. Doctors should also advocate for other ways to treat their patients' pain, such as the multidisciplinary approach that research supports (Quinones 124). However, this type of comprehensive care can be expensive, so doctors should advocate for their patients by urging insurance companies to cover this pain treatment and aid their patients in finding affordable options.

The second piece to addressing this crisis is helping those already addicted to opiates. First, the medical community must advocate for the destigmatization of opioid use. Although the nation is more accepting of addiction as a disease, much work still needs to be done. All students should be educated on the opioid epidemic and given more helpful strategies on avoiding improper use and recognizing and helping others who may need help. The medical community must work to keep addicts out of prison to ensure they get the proper treatment. Physicians can work to destigmatize and advocate for harm reduction tactics such as opiate maintenance treatment with buprenorphine and supervised injection sites where patients can access clean materials and medical supervision. Healthcare providers should push to expand the opiate rehabilitation infrastructure because the current framework is insufficient. These centers are swamped by the sheer number of people needing these services, and they are unaffordable and inaccessible for many (Quinones 249). Opioid rehabilitation success rates are abysmal, with around 1 in 10 users staying clean because most do not get the complete treatment they need (Quinones 329). Many users only get three to six weeks inpatient, but research shows this is insufficient for brain recovery (Quinones 329). If the healthcare system amends infrastructure and expands it, treatment will be feasible for more people. Recently, the medical community expanded public education on how to recognize an opioid overdose and continues the distribution of Narcan. These programs must be continued and expanded as well.

Finally, although the average American bears no responsibility for creating the crisis, everyone is obligated to work towards a solution. We all have a stake in the issue. Addiction does not discriminate; it crosses demographic and social barriers, and we have no bearing on who is affected. Thus, we are all responsible for fixing the problem plaguing our communities. In fact, Quinones says that the “antidote to heroin is community” (Quinones 253). He makes the case that if we want to prevent our loved ones from seeking heroin, we have to engage them in the neighborhood. He calls for breaking down barriers that isolate people from each other and advocates for getting kids outside (Quinones 253). This idea sounds nice, but Quinones is too idealistic in his delivery. Of course, people will benefit from greater community and concern for each other, but this is hard to implement and will certainly not be sufficient. Community engagement must be a small piece of solving the opioid epidemic. A multidisciplinary approach led by Purdue pharmaceuticals and the entire medical community is necessary to resolve the crisis.

Reference

Quinones, S. (2016). Dreamland: the true tale of America's opiate epidemic. New York, NY: Bloomsbury Press.