Big Opioid and the Pain Movement

The Pain Movement claimed “untreated pain” was America’s number one health problem

Purdue “fostered the sense that pain care was a movement.” (4) Largely confined to the USA and Canada, this movement sought to change pain treatment. Toronto Symposium attendees considered morphine an excellent medicine unfairly stigmatized by overblown addiction concerns. One Symposium expert assured: “addiction does not occur in patients requiring morphine for pain control.” (5)

The Pain Movement claimed “untreated pain” was America’s number one health problem. (6) This “pain epidemic” took many forms: cancer pain, back pain, neck pain, arthritic pain, postoperative pain, sports-and-workplace injury pain, fibromyalgia etc.

Pain Movement leaders complained: “physicians had been far too reluctant to administer morphine.” Richard Sackler argued morphine’s stigmatization derived from: “a popular misunderstanding shared by both professionals and laymen that morphine was an end-of-life drug… a death sentence.” (7)

To Big Pharma the opioid stigma blocked access to vast untapped markets. Cancer pain was chosen as the wedge issue to break through this barrier. (8) The campaign had to appear to come from outside of drug companies. (9) They needed “non-branded literature.” (10) Having made their fortune in pharmaceutical sales, and pharmaceutical journal publishing, the Sacklers understood non-branded literature.

An exemplar of such crypto-advertizing was “Addiction Rare in Patients Treated With Narcotics” – a 5-sentence letter-to-the-editor written in 1980 by two data-miners and published in New England Journal of Medicine (NEJM). Their unbelievable findings:

“Although there were 11,882 opioid-using patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients that had no history of addiction.” (11)

For 25 years opioid boosters flogged this letter as a peer-reviewed study. Scientific American called it “an extensive study.” Time dubbed it a “landmark study.” (NEJM archives didn’t go online until 2010 thus the letter was only accessible at university medical school library archives.) The letter dealt with small amounts of opioids briefly prescribed in hospital settings, not large amounts of take-home pills. (12)

Pain Movement organizations like Pain Care Forum, American Academy of Pain Medicine, American Pain Foundation and Academy of Integrated Pain Management shepherded a sprawling coalition of patient advocacy groups and professional associations. A 2018 Homeland Security study found opioid manufacturers had (over 5 years) given $9 million to 14 pain groups – and $10 million to the individuals (usually physicians) heading those groups. (13)

By 2001 Pain Movement leaders boasted of achieving a “paradigm shift” in attitudes toward opioids

Purdue government relations exec, Burt Rosen, ran the Pain Care Forum. Dr. Russell Portenoy (‘the King of Pain’) presided over American Pain Society and helped manage American Pain Foundation. Portnoy also chaired Beth Israel’s Department of Pain Medicine, and drew income from Purdue. Big Pharma execs presumed Pain Movement orgs would accept directors, and direction, from Big Pharma. (14)

By 2001 Pain Movement leaders boasted of achieving a “paradigm shift” in attitudes toward opioids. (15)

As for lobbying clout, Richard Sackler crowed:

“We can get virtually every senator and congressman we want to talk to on the phone in the next 72 hours.” (16)

The movement captured key agencies. Veterans Health Administration declared pain the “fifth vital sign.” The Joint Commission for Accreditation of Healthcare Organizations (which accredits 16,000 organizations) followed suit. California legislation required doctors to screen for pain along with other vital signs. This legislation was copied by other states as was another California law exempting doctors from prosecution for responsibly prescribing opiates for chronic pain. (17)

Homeland Security estimated opioid manufacturers:

“…spent more than $880 million nationwide on lobbying and campaign contributions from 2006 through 2015 – more than 200 times what those advocating stricter (opioid) policies spent.” (18)

Another investigator reported:

“…drug companies that manufacture opioid painkillers spent over $700 million between 2006 and 2015 on lobbying in Washington and all 50 states. The combined spending of these groups amounted to 8 times what the gun lobby spent….One former DEA official described the influence that this lobby exerted over Congress as a “stranglehold.” (19)

Circa 2010, after the Center for Disease Control (CDC) and the DEA suggested restricting opioid sales, Richard Sackler seethed:

“We are in the middle of a real fight… This is a clear attack on the pain movement.”

He resolved to bind movement orgs more closely to Purdue. (20)

OxyContin

Contins are pill coatings that slow the release of a pill’s medicine. Contin coatings were invented by Napp plc – a British firm later acquired by the Sacklers. (21)

By 1984 Purdue’s MS Contin (a slow-release morphine sulphate pill) was “revolutionizing the Canadian narcotic analgesic market.” (22) Canadian addicts dubbed MS Contins “purple peelers” because their coatings peeled off easily. Purdue knew about this practice. (23)

Wary of morphine’s addictiveness, most physicians prescribed MS Contin for palliative care only. Eliminating such reticence was the Pain Movement’s principal goal. By 1994, 750,000 US cancer patients took MS Contin. Purdue estimated the US cancer pain market might sustain 4 million MS Contin customers. (24) Thus, the Sacklers dreaded MS Contin’s impending patent expiry which meant generics would soon invade this market. (25)

Katherine Sackler claims Contin-coated oxycodone as her brainchild. (26) Because oxycodone packs twice the punch of morphine the idea suggested itself. Oxycodone was already popular. Percodan is tiny amounts of oxycodone mixed with aspirin. Percocet is tiny amounts of oxycodone mixed with acetaminophen.

In December 1995 the FDA approved OxyContin, thenceforth:

“…if Purdue wanted to market a powerful opioid like OxyContin for less acute, more persistent types of pain, one challenge would be the perception, among physicians, that opioids could be very addictive… Purdue would have to undue that perception.” (27)

One month later Purdue launched OxyContin at an extravaganza in a five-star Phoenix resort. Their slogan:

“OxyContin: the painkiller to start with and stay with.”

Sales reps were instructed to tell doctors that “fewer than 1%” of OxyContin patients became addicts. Slow-release coatings meant OxyContin gave no “kick.” There was no peak-and-trough typical of narcotics. OxyContin killed pain like heroin, yet was non-addictive. This sales pitch was FDA-approved. (28)

Purdue pushed OxyContin more aggressively than any previous opioid. They handed-out OxyContin-logoed ball-caps, plush-toys and luggage-tags. They spent millions taking doctors to lunch. (29)

“OxyContin: the painkiller to start with and stay with.”

“The company established a speaker’s bureau, through which it paid several thousand doctors to attend medical conferences and deliver presentations about the merits of strong opioids. Doctors were offered all-expenses-paid trips to ‘pain management seminars’… In the initial five years after OxyContin’s release, the company sponsored several thousand of these seminars.” (30)

(Internal docs show Purdue execs salivating over “pediatric indication.” In 2011 Purdue made it a goal to have OxyContin approved for children. In 2015 the FDA OK’d OxyContin for kids as young as 11.) (31)

In 1997 Purdue began monitoring Internet chatroom discussions of illicit OxyContin use. Meantime, huge sales volumes in towns like Bensalem, Penn betrayed obvious illicit OxyContin diversion. Dr. Portenoy, (who later testified against Purdue) confirmed that Purdue knew of largescale diversion by the late-1990s. (32) By 2001, 20% of OxyContin prescriptions were renewed too frequently. An internal memo whispers: “These numbers are very scary.” (33)

At a 2001 US House of Representatives Subcommittee hearing in Bensalem, Purdue spokesmen declared: a) 50 million chronic pain sufferers mustn’t be criminalized; b) diversion is law enforcement’s responsibility; c) OxyContin abuse is part of a larger trend of prescription drug abuse; d) opioid de-stigmatization isn’t to blame; and, e) Purdue is an ethical corporation. Purdue pulled their 160mg whopper off the market. They gave away tamper-proof prescription pads and ran ads telling kids not to steal their parents’ dope.

Purdue spokesmen told two flat-out lies: a) Purdue never knew about MS Contin diversion; and, b) Purdue first learned of OxyContin abuse from Maine newspapers in April 2000. (34)

Purdue’s PR supremo, Howard Udell, coined the term “pseudo-addiction.” Undeniably, OxyContin patients experienced withdrawal symptoms (nausea, itching, shaking) before their dosing cycles ended. This pseudo-addiction, according to Udell, was actually unrelieved pain. Symptoms ceased when pain is relieved. Pseudo-addiction’s remedy …up the dosage. (35)

Not until 2010 did Purdue introduce a safer OxyContin. With its gummy bear texture, OxyContin OP, proved difficult for addicts to extract oxycodone from. By 2010, however, opioid abuse had exploded. Moreover, by 2010 the Sacklers secretly owned one of America’s largest generic oxycodone manufacturers. Located in a remote, high-security Rhode Island facility, Rhodes Pharma churned out uncoated, non-gummy oxycodone pills. Sacklers created Rhodes after pleading guilty to deceptive advertising in Virginia in 2006. (36)

Pill Mills Kill Hillbillies

Sacklers’ stratospheric wealth predates OxyContin. Raymond had been knighted in France and England. Luminaries of the global plutocracy graced his Long Island palace. Sackler philanthropy was world renowned. Conversely, OxyContin addicts were third-class Americans – “white trash.”

Pill mills are clinics staffed by unscrupulous doctors who write opioid prescriptions for anyone who asks. Setting up a pill mill simply requires leasing a retail space and hiring a medic with a DEA-issued Schedule II narcotic prescribing permit. (37)

In 1990s pill mills cropped up in America’s rural white towns. OxyContin initially gained popularity in Appalachia, hence the nickname “hillbilly heroin.” (38) Purdue sales reps in poor rural areas of Ohio and Kentucky harvested yearly commissions of $500,000. A pioneering pill mill in Ohio’s Scioto County, paid doctors to prescribe OxyContin. Soon Scioto’s 72,000 residents popped 10 million Oxys a year. (39)

This passage from Keefe is telling:

“By 2008, the US was in the throes of a full-blown opioid emergency, and people had started to talk about a public health crisis. The plague of addiction was no longer confined to rural areas.” (40)

Note: the push started in 1996 yet for 12 years it was “confined to rural areas.”

Pill mills are easily locatable through sales data. A clinic in a West Virginia town with a population of 3,200 distributed 2 million pills annually. (41) A doctor in Garrison, Kentucky wrote 46,000 opioid prescriptions in 9 months (average consultation time: 90 seconds). Pill mill doctors came to work with preprinted opioid prescriptions. (42) One Ohio doctor charged $200 per consultation, wrote huge prescriptions; and pocketed over $1 million per year for three years. (43)

Pill mills are also visually obvious. (DEA agents looked customers wearing pajamas.) (44)

Myrtle Beach’s Comprehensive Care operated out of a strip mall. Morning ‘til night line-ups stretched out the door. Cars with out-of-state plates jammed the lot. Purdue moved $5 million of OxyContin a year through Comprehensive Care, before the DEA shut it down. (45)

Lake Medical set-up shop in 2008 near L.A.’s MacArthur Park. Dr. Santiago wrote prescriptions for 80mg pills which when ground-up, diluted and re-packaged fetched $80 each on the street. Lake Medical vans prowled Skid Row and L.A. County Jail exits for “patients” who were paid $25 to have medical exams before being driven to pharmacies with their scripts. Lake Medical looked abandoned. A Purdue sales rep ventured inside to chat with Dr. Santiago only to spin around upon glimpsing his patients. She memo-ed headquarters: “Call the DEA!” HQ did no such thing. They joked about how long the racket could last. Finally, LAPD busted it. Between memo and bust Purdue moved a million 80s through Lake Medical. (46)

OxyContin and other legal opioids laid paths to heroin and other illegal opioids

In 2013 the Los Angeles Times reported:

“…the maker of the potent painkiller OxyContin has compiled a database of hundreds of doctors suspected of recklessly prescribing its pills to addicts and drug dealers, and has done little to alert law enforcement or medical authorities.”

Purdue’s secret “Region Zero” dossier listed 1,800 pill mills! Purdue claimed they snitched on 8% of these outfits. In reality, they waited until the jig was up before blowing the whistle. (47) Purdue lobbied state legislators to keep them open. (48)

Meanwhile, OxyContin and other legal opioids laid paths to heroin and other illegal opioids. After 2010 it became harder to get OxyContin. When authorities closed pill mills addicts switched to heroin. A Purdue chemist who helped develop the drug quipped: “OxyContin was the tip of the spear.” (49) CDC Director Tom Frieden said Americans were “primed” for heroin with prescription opioids. (50)

Nevertheless, to Purdue’s Udell OxyContin remained: “a magnificent gift that the Sacklers had bestowed upon humanity that was now being sullied by a nihilistic breed of hillbilly pillpoppers.” Asked about overdoses, Udell responded: “not my problem.” (51)

Purdue insisted: “the voice of pain patients should be at the forefront of discussions and should not be upstaged by a bunch of reckless drug addicts.” (52)

Richard Sackler deployed notoriously “hateful rhetoric” toward OxyContin addicts. Emails between Richard and a confidante, regarding negative publicity surrounding OxyContin, are revealing:

“The whole thing is a sham,” a sympathetic friend reassured him (Richard). If people die because they abuse the drug, “then good riddance.” Richard replied “Unfortunately, when I’m ambushed by 60 Minutes, I can’t easily get this concept across …Calling drug addicts ‘scum of the earth’ will guarantee that I become the posterchild for liberals….” (53)

More Richard Sackler-isms:

“…the media has nefariously cast the drug abuser as a victim instead of a victimizer.”

“These are criminals. Why should they be entitled to our sympathies?”

“Addicts want to be addicted.” (54)

Same Old, Same Old…

Prior to the class-action lawsuits and superficial corporate restructurings, Purdue held a 30% opioid market share. (55) Purdue wasn’t alone in deceptively marketing opioids. Johnson & Johnson (J&J), Endo, Mallinckrodt, Allergen and Teva confessed to the same. They were joined by distributors Cardinal Health, AmerisourceBergen and McKesson, and retailers CVS, Walgreen and Walmart, all of whom admitted to shovelling opioids into a market rife with illicit diversion and lethal addiction. (56) Little has changed since, upwards of 20 million Americans are currently prescribed opioids. (57)

J&J played an outsized role in the opioid bonanza. They supplied the thebaine from which oxycodone is made. After bio-engineering a thebaine-rich poppy, J&J’s Tasmanian Alkaloid facility produced 85% of the world’s thebaine. With the Australian government’s blessing 110 square miles of Tasmanian farmland around this facility is licenced to grow GMO poppies. Between 1994 and 2015, with DEA blessing, US thebaine imports increased enormously, and oxycodone production quotas were raised 36 times. (In 2016 J&J transferred Tasmanian Alkaloid, renamed Extractas Bioscience, to SK Capitol.) (58)

The 4,000 state, provincial and municipal class-action lawsuits against Big Opioid settled for a cumulative $55 billion. (59) Battles swirl around who gets this loot. Never missing a beat, Big Opioid lobbies for shunting these funds toward “Harm Reduction” i.e., drug paraphernalia give-aways, state-run shooting galleries, and opioid de-stigmatization. Settlement funds purchase Methadone, Naloxone, Buprenorphine and other opioids manufactured by you-know-who.

The Pain Movement and Harm Reduction Are One

The Pain Movement slayed its sibling rival – multidisciplinary pain management. This competitor operated hundreds of clinics before insurance companies, on Pain Movement orders, cut-off funds. To treat chronic pain multidisciplinary pain managers called upon physiotherapists, surgeons, pain psychologists, occupational therapists, nutritionists, weight loss experts and fitness coaches. Opioids were their last resort because they knew the danger of addiction. They rightly stigmatized opioids.

Inversely, the Pain Movement spreads disinformation about opioid addiction risks. The movement’s former miseducator-in-chief, Dr. Portenoy, later confessed:

“In essence this was education to destigmatize (opioids), and because the primary goal was to destigmatize, we often left evidence behind.” (60)

Destigmatizing opioids is also central to Harm Reduction. Both the Pain Movement and Harm Reduction consist of opioid producers and distributors, physicians, pharmacists, academics, plus a plethora of NGOs. Both movements:

• overlap with, and act upon, the healthcare industry;
• lobby regulatory agencies with pseudo-medical information;
• pursue semi-legalization and popularization of opioids;
• aid and abet the criminal opioid industry; and,
• facilitate and cause increases in opioid addiction.

Activities of both movements date from 1980ish to the present. Both focus on the USA and Canada. Both initially targeted underemployed whites, although over time their collateral damage extended into other ethnicities and classes. Same, same…

FOOTNOTES

1. Trebach, Arnold S. The Heroin Solution; Yale University Press, New Have and London, 1982, p. 12.
2. Center for Disease Control Overdoses
3. Keefe, Patrick Radden. Empire of Pain, The Secret History of the Sackler Dynasty, Penguin Random House, Canada, 2021, p. 175-7.
4. Ibid, p. 249-50.
5. Ibid, p. 175.
6. Ibid, p. 346-7.
7. Ibid, p. 176.
8. Ibid, p. 367 and 183.
9. Ibid, p. 249-250.
10. Ibid, p. 210.
11. The Atlantic Monthly. Zhang, Sarah. The One Paragraph Letter from 1980 that Fueled the Opioid Crisis; June 2, 2017.
12. Quinones, Sam. Dreamland: The True Tale of America’s Opiate Epidemic; Bloomsbury, New York, 2015, p. 108.
13. Homeland Security and Government Affairs Committee, Fueling an Epidemic: Report Two – Exposing the Financial Ties Between Opioid Manufacturers and Third Party Advocacy Groups, 2018, p.3 and 10.
14. Keefe, p. 250.
15. Ibid, p. 367.
16. Ibid, p. 249.
17. Quinones, p. 95.
18. Homeland Security, page 15.
19. Keefe, p. 346-7.
20. Ibid, p. 250 and 346.
21. Ibid, p. 175.
22. Ibid, p. 177.
23. Ibid, p. 240.
24. Ibid, p. 183-4.
25. Ibid, p. 178.
26. Ibid, p. 178.
27. Ibid, p. 184.
28. Ibid, p. 208-9.
29. Ibid, p. 211.
30. Ibid, p. 210.
31. Ibid, p. 357.
32. Ibid, p. 376.
33. Ibid, p. 232.
34. Ibid, p. 238-9.
35. Ibid, p. 234.
36. Ibid, p. 366.
37. Quinones, p. 197.
38. Keefe, p. 314.
39. Snyder, Timothy. The Road to Unfreedom: Russia, Europe, America, Penguin Random House, New York, 2019, p. 263-6.
40. Keefe, p. 294-5.
41. Snyder, p. 263-6.
42. Quinones, p. 158.
43. Ibid. p. 198.
44. Ibid. p. 160.
45. Keefe, p. 235-6.
46. Ibid, p. 295-7
47. Ibid, p. 338.
48. Ibid, p. 346-7.
49. Ibid, p. 367.
50. Ibid, p. 346-7.
51. Ibid, p. 233.
52. Ibid, p. 249-50.
53. Ibid, p. 236-7.
54. Ibid, p. 256-7.
55. Ibid, p. 364-5
56. KFF Heath News Opioid Settlement
57. CDC National Center for Health Statistics June 2020 – Prevalence of Prescription Pain Medication 
58. Extractas Bioscience see also Keefe, p. 363-4.
59. Opioid Settle Tracker
60. Quinones, p. 309.