Marketing and Development: The Strategy of Addiction

The Opioid Crisis in Context

In 2015, for the first time in a century, life expectancy in the United States experienced a marked decline—from 78.7 years in 2014 to 78.7 years in 2015, and eventually to 78.5 years in 2016 and 2017. This decline upset a centuries-long trend of increasing life expectancy in developed countries, one that has only been mirrored by the Spanish flu pandemic from 1915-1919 and the ongoing Covid-19 pandemic (DeWeerdt). What makes this marked decrease so notable, though, is that it was not due to any infectious pathogen, nor natural disaster or disruption in the infrastructure that makes modern life possible; rather, this decline was due largely to drug-related overdoses and suicide, as described by the CDC in their briefings on America’s ongoing opioid epidemic. Indeed, the word epidemic is particularly salient now; the effects of opioids have become so entrenched and so ubiquitous in our modern day conversations on public health that we have borrowed the language we typically use to frame public health crises caused by infectious diseases. This word carries a connotation of not only death, but of uncontrollable death, a systemic problem that in all of our understanding of public health we cannot seem to curtail nor describe in full where the problem began, or will end. We can, however, try to attribute some responsibility to those who arguably sowed the seeds of the current opioid epidemic.

Throughout this project we have traced the history of opioids from the Chinese Opium Wars to the American Civil War, and have witnessed opioids being used historically as a tool for imperialism through the vehicle of mass addiction and as troubled remedies for victims of war. The current opioid epidemic blends these two historical understandings of opioids together, weaving through the complicated attempt of physicians to find treatments for chronic pain while fielding the profit-driven marketing of pharmaceutical companies. This section will focus primarily on the development of OxyContin by Purdue Pharmaceutical, and the strategies it utilized in framing OxyContin, both to federal agencies and physicians across the nation, as a “new opioid” for the treatment of chronic pain.

It is also important to understand opioid’s biological mechanisms. Opioids mimic endogenous chemicals within the human nervous system known as endorphins, which are responsible for regulating a variety of human physiological processes including pain reception, mood, and nervous system stimulation. Opioids bind to the same set of receptors as endorphins, but most prominent here is the mu opioid receptor. When activated by a naturally occurring endorphin, these mu receptors can act to boost mood or increase pain tolerance; a pertinent example is the rush of endorphins an athlete may feel after a hard work out. When activated by a foreign opioid, these receptors are often overloaded, with effects that are amplified beyond what natural endorphins could cause. Increased pain tolerance becomes full-blown analgesia, a mood boost becomes euphoria, and relaxation becomes central nervous system depression. This is what makes opioids so addictive, at least from a psychological perspective: they imitate one of our body’s natural reward system and take it far beyond what is naturally achievable. Furthermore, longterm use of opioids causes mu receptors to become desensitized to natural endorphins, meaning that withdrawal symptoms accompany any disruption in opioid intake: missing a dose can lead to dysphoria, phantom pain, and anxiety as the nervous system struggles to cope without the depressant it has grown used to (Strain).

Morphine (left) compared to an endogenous endorphin (right), demonstrating their similar chemical structures (Papini)

Pain as an Illness, OxyContin as a Cure

Before understanding OxyContin’s marketing, we must first understand the condition Purdue sought to appeal to. Throughout the 1980s, physicians increasingly began to understand chronic pain as its own condition worthy of treatment—the American Pain Society was at the forefront of challenging contemporary understandings of what an illness could be. Their philosophy highlighted the fact that pain was not only a symptom of a larger illness. Rather, pain could itself be an illness, capable of interrupting the daily life of a chronic pain sufferer. Historically, opioids had been used only for short-term indications such as post-surgery recovery or, in more drastic cases, for those suffering from pain caused by chronic and often terminal illnesses such as cancer (Chakradhar and Ross).

Purdue Pharma became aware of this push towards understanding pain as its own illness, and saw an opportunity for expanding opioids for use in “non-cancer patients with chronic pain,” which would become a phrase repeated often in the email correspondences of Purdue executives and marketing strategists. Recent breakthroughs from Purdue’s R&D team had led to the discovery of a new tablet technology that allowed ultra-concentrated amounts of oxycodone, a well-known opioid at this point, to be released slowly from a pill over the course of several hours as opposed to the immediate release of other oral opioids. Purdue saw an opportunity here to market this new drug, OxyContin, as a less addictive alternative to other oral opioids: their reasoning being that those seeking a high would prefer the immediate release of traditional opioids to the multi-hour release of OxyContin. This reasoning, in fact, was enough for the FDA to approve Purdue’s language in its marketing of OxyContin, which, according to the FDA, was substantial enough to warrant a response that OxyContin was “believed to reduce” oxycodone’s addictive potential (Levitz). Purdue took this approval and ran, and through its advertisements and private dinners with doctors and pain specialists, lauded OxyContin’s non-addictive nature.

Marketing a New Opioid

Purdue treated physicians to lavish dinners and even all-expense-paid vacations domestically and abroad, with its marketing team finding that physicians that went on these trips were twice to three times more likely to prescribe OxyContin to chronic pain sufferers. Purdue was careful in the language used to market OxyContin; while they emphasized that OxyContin had hardly any addictive potential and lacked the potential for tolerance of traditional opioids, they were nonetheless insistent in their marketing that OxyContin was “as ‘effective’ as morphine, but we do not want to say that OxyContin is as ‘powerful’ as morphine” (“Minutes of Phase IV OxyContin Tablets Team”). This distinction, Purdue supposed, was meant to distance OxyContin from the traditional understanding of opioids’ addictive potential. Sales representatives were instructed that their priority was to “Sell, Sell, Sell Oxycontin” in a company-wide memo in January 1999 (“OxyContin Sales Bulletin”). As mounting evidence compiled by American oncologists pointed to the fact that OxyContin may have had a “ceiling effect”—refuting Purdue’s claim that tolerance did not occur as with other opioids—Richard Sackler, chairman and president of Purdue Pharma, sought advice on how to “smash this critical misconception” (Sackler). Then-sales and marketing executive Michael Friedman disagreed with Sackler on this strategy, but nonetheless Purdue Pharma continued to market OxyContin as a drug with less of a potential for tolerance.

Take this advertisement from Purdue Pharma circulating in a physicians-only journal of new drugs:

Cracks in the Narrative

The advertisement conveys perfectly Purdue’s attitude towards its marketing of OxyContin. Purdue’s chief goal was to convey primarily to physicians that OxyContin provided an “easy” treatment to chronic pain where other opioids did not—OxyContin was, of course, extremely effective at combating pain for the first few months of treatment, but Purdue’s advertisements left out in entirety the mounting evidence that OxyContin came with the same risk of tolerance and addiction as other opioids. Rather, the company focused on what OxyContin did do well, at least initially: it controlled pain, it only required two doses a day, and it was long-lasting. The fact that America’s healthcare system is primarily composed of private practices meant that a drug as easy and as initially effective as OxyContin was a massive appeal to physicians—more effective, easier treatments meant more patients, which meant more income for physicians.

By the fall of 2000, however, the Kentucky OxyContin Task Force deemed that illegal use of OxyContin had grown to “epidemic proportions” (Burks). Members from Purdue Pharma agreed to join this task force, but internal documents revealed their true motivation: “We have sold more OxyContin than ever. This program will ensure that our sales will continue to increase,” said one Jane Doe sales representative in 2002. By 2014, after a decade of inaction from Purdue and governmental authorities, the Commonwealth of Kentucky finally filed a lawsuit against Purdue Pharma, alleging that Purdue had 78 sales representatives assigned to Kentucky alone that misadvertised and inappropriate marketed OxyContin to physicians throughout the state, and alleged that this behavior led directly to the increased use of not only OxyContin but of other legal and illegal opioids in the state (Chakradhar and Ross).

Dr. William T. Fannin swears in an Affidavit in the suit against Purdue the following:

“I was advised by the manufacturer of Oxycontin, through its employees and marketing materials, that Oxycontin was less addictive, less prone to tolerance, and less prone to abuse than other opiates.” As a result of these representations, “I prescribed Oxycontin to patients who suffered adverse health consequences [...] It is my belief … the marketing of Oxycontin in the above-stated manner resulted in numerous health consequences to patients and other individuals in Kentucky, especially those in Eastern Kentucky.”

Conclusions

In his article on Purdue’s strategic marketing of OxyContin, Eric Levitz perhaps summarized the beginning of the opioid crisis best:

“Like so many of our nation’s current crises, the opioid epidemic was born of a highly profitable lie: that extended-release opioid painkillers were far less addictive than the ordinary kind” (Levitz).

As a result of Purdue Pharma’s intentional misrepresentation of OxyContin, and its close relationships with physicians operating with profit as a leading motive, thousands of individuals seeking help for chronic pain ended up developing opioid use disorders that, for many, were lifelong. Indeed, in seeking to satisfy their addictions, many lost their lives. Despite the fact that Purdue knew that its drugs were just as addictive as previous opioids by the late 1990s, it has only been towards the latter half of the 2010s that regulations on opioid prescriptions by doctors and mandated patient information campaigns regarding how to wean off of opioids have become the norm. For those who were forced into the spiral of addiction by Purdue Pharma, it is unfortunately too little too late; Purdue Pharma’s greed has set into motion a public health crisis with which we are still grappling.

A Personal Note

I (Brandon) chose to research and write this section because I have been personally touched by the actions of Purdue Pharma: my father was one of many patients prescribed OxyContin due to chronic pain or injury, and, at the time, he was led to believe that the medicine was not addictive and did not require any special attention to cease use. His story is unfortunately typical, and only a few years after being prescribed OxyContin, his addiction took him from my family while I was still young. I have been particularly touched by the research my group-mates and I have done this semester, and I want to express my gratitude to Professor Hepler-Smith and Emily for guiding me towards a deeper understanding of something that has had such a profound impact on my life.