Three months after declaring the opioid crisis a national emergency, President Trump declared during his first State of the Union that the United States would beat the epidemic by getting “much tougher on drug dealers and pushers.” Such combative rhetoric draws attention away from the real narrative behind America’s biggest drug epidemic: bad government policy catering to special interests.
The Rise and Fall of OxyContin
Prior to the 1990s, doctors generally viewed opioids as a last resort due to their addictive properties. Two medical perspectives shifted. First, a 1992 federal report concluded that fear of opioid addiction prevented too many patients from receiving the pain relief they needed. Around the same time, medical professionals began to accept chronic pain as a legitimate reason for treatment, with or without the presence of other symptoms.
The resulting medical paradigm shift led to a spike in the demand for painkillers, and pharmaceutical companies raced to satiate the growing market. Purdue Pharma developed the opioid OxyContin and released it in 1996. In its first year, OxyContin reeled in $48 million of revenue for Purdue. Through an aggressive marketing campaign, annual revenue increased to $1.1 billion by 2000.
To turn its opioid from a last resort to a national phenomenon, Purdue Pharma aggressively marketed OxyContin to first-care physicians. From 1996 to 2001, Purdue held over 40 pain management conferences, covering all expenses for over 5,000 visiting physicians. At these conferences, Purdue recruited and trained physicians for its national speakers bureau. Research indicates such symposia have a significant effect physicians’ prescribing practices. In addition to its conferences, Purdue greatly expanded its sales representative force. After spending just $1 million in sales incentive bonuses to its sales team, Purdue increased incentives to $40 million by 2001. Direct-to-consumer advertising was also intense: Purdue offered tens of thousands of free samples to physicians and free trial coupons to patients.
Aggressive marketing like this was new to the painkiller market. During OxyContin’s first six years in the market, Purdue spent six to twelve times as much on marketing OxyContin than two of the leading prescription opioids before it over the same period. Purdue’s marketing strategy proved effective. OxyContin prescriptions increased nearly tenfold from 1997 to 2002, from 670,000 to 6.2 million.
Other pharmaceutical companies followed Purdue’s example. Through advertisements in high-ranking medical journals, funding of non-profit research organizations, and promotion of educational materials for medical professionals, both physicians and consumers grew used to opioids as an all-purpose painkiller. In 2010, 254 million prescriptions for opioids were filled, enough to medicate every American adult for a month.
The marketing did not simply place OxyContin in the public eye; it also shaped perception of opioids. Purdue trained its sales force to assure doctors that the chances of a patient becoming addicted to OxyContin were less than one percent due to its time release formula. Evidence suggests Purdue was fudging these numbers - and knew so, as early as 1997. One cannot help but wonder if the subsequent aggressive marketing was to compensate the product’s dangerous properties. Sure enough, as OxyContin became a more common resident in Americans’ medicine cabinets, so did opioid addictions become a growing problem. During OxyContin’s peak in 2010, nine million Americans abused prescription medication.
Much of the proliferation of opioid prescriptions are attributable to primary care physicians, who were the main target of the pharmaceutical companies’ promotional efforts. Half of all OxyContin’s prescriptions in its early years were filled by primary care physicians, who have limited training in prescribing medications. Combine the lack of expertise with the inherently addictive nature of opioids, and patients are in a position to demand more prescription painkillers than they actually need.
Subsidizing false advertising
How did one of the most aggressive marketing campaigns in pharmaceutical industry become the most attractive strategy for a drug that proved more dangerous than originally imagined? Despite the magnitude of marketing in Purdue’s balance sheet, it may have been a cost-effective option.
Corporate tax law permits businesses to deduct advertising and promotion costs from its taxable income. There are limited restrictions on this permission. So long as the expenses are attributable to reaching customers, managing a brand, or promoting information about the product, the business can write off those costs. For instance, every conference Purdue Pharma hosted qualifies as a special promotional event and is deductible.
The pharmaceutical industry’s influence on the federal government is well-documented. During the last twenty years, companies producing pharmaceutical and other health products have spent nearly $4 billion on lobbying, more than any other industry and over a billion dollars greater than the next-largest lobbying industry, insurance. Millions of these dollars go toward fighting legislation intending to curb prescriptions and emphasizing user error in the opioid epidemic.
According to Joseph T. Rannazzisi, a former head of the Drug Enforcement Agency’s Office of Diversion Control, pharmaceutical companies often knowingly delivered prescription medication to underqualified pharmacists and doctors. From 2008 to 2017, pharmaceutical distributors were fined hundreds of millions of dollars. In 2017, pharmaceutical lobbyists spent $1.5 million dollars in their successful push to restrict the DEA’s enforcement of these shipments.
It’s easy to blame “big pharma” for its role in the opioid crisis, but critics usually fail to recognize that the very government they call on to regulate the industry is the same government facilitating the irresponsible behaviors. At their best, lobbyists can be helpful educators, but lawmakers must be held accountable for the influences they subject themselves to. Public transparency is necessary for true popular representation in the United States.