Big pharma made big mistakes – strategic marketing of opioids caused the overdose epidemic. How did it all start and what can be done about it?
The opioid dispensing rate decreased in the past years – yet opioid use disorder in America is not short of a crisis. Around three million US-Americans suffered or are currently suffering from this disorder. Retiring physicians who previously prescribed opioids to their chronic pain patients created a demand that is not being fulfilled by other physicians – black markets are thriving, and the demand for illicit drugs is increasing with every new regulation and monitoring approach that is implemented.
The opioid crisis began with the approval of OxyContin® by the Food and Drug Administration (FDA) in 1995. OxyContin® is an opioid analgesic containing the active substance oxycodone. This opioid affects receptors of the central nervous system, where it acts as an agonist of the µ-, κ-, and δ-opioid receptors. Peroral intake has double the potency of morphine, hence why it is usually prescribed as an analgetic for cancer patients or after traumatic surgeries. But Purdue Pharma – the manufacturer of OxyContin® – had other plans for their new drug. Their mission was to sell as many pills as possible to a broad spectrum of people – not only cancer patients.
They coupled the active substance to a controlled-release-mechanism that allowed for dosing every 12 hours instead of every 4 to 6 hours like other painkillers. They stated the slow absorption would lead to a lower abuse potential of the drug. Even though the studies on which the FDA based their future decisions about OxyContin® were lacking in substance (e. g. one study only lasted two weeks), PP received permission to market and sell their drug – and this is where it all went awry.
The marketing strategy of Purdue Pharma was based on loyal customers. Physicians who previously prescribed the opioid MS Contin® (a morphine-sulfate-based drug by PP) were targeted to kick off their sales. They were viewed as potential “bridges”, not only to enter the market but to target non-cancer-patients. Sales representatives were sent to these doctor‘s practices and provided a one-on-one service. Good customer service was crucial to Purdue Pharma’s marketing strategy.
Purdue Pharma had to get two groups hooked: the physicians to the company and patients to their new drug. To attract and retain physicians, the sales reps regularly visited the practices and were trained to push sales and highlighted the importance of regular prescription of the drug and how important it is to administer it every 12 hours. Family physicians who regularly prescribed OxyContin® to their patients were invited to dinner parties. Even merchandise like plushies, CDs, and fishing hats were handed out.
Getting patients hooked on their drug was much simpler: Sales representatives handed out coupons to the physicians, which they could give to their patients. These coupons were “free trials” for seven to 30 days of pill supply. Due to oxycodone’s high addictive potential that was enough to get patients to rely on those pills. As the sales reps bonuses were dependent on the number of pills their physicians prescribed – it comes as no surprise that they pushed doctors to prescribe OxyContin® for a broader spectrum of symptoms – even though it was only labeled for the treatment of severe pain.
In early 2000 the number of OxyContin®-related overdoses and deaths began to rise. In 2003 the FDA wrote a warning letter to Purdue Pharma due to false advertisement on their part. They requested clarification and correction of their statements in ads and journals, in which PP minimized the risk of OxyContin® and “fail to present in the body of the advertisements any information from the boxed warning in the approved product labeling (PI) for OxyContin regarding the potentially fatal risks associated with the use of OxyContin and the abuse liability.“
But at that point, the harm was already done – from 2004 to 2009 there was an 98 % increase in the abuse of pharmaceuticals. The repercussions are visible even to this day. Due to the lack of appropriate care and lacks of funding for help programs, individuals with opioid use disorders are left on their own – forced to use unauthorized channels and thus fueling the black marked.
Overdose-related deaths with the involvement of opioids are still at an all-time high in the past years, with around 80.000 deaths in 2022 alone. As a result, physicians have become more careful when prescribing opioids like Oxycodone. Naturally, this is a good sign, as it will ultimately lead to fewer new opioid users. But what about those, who already are reliant on Oxycodone and other opioids and whose access to those is now denied? And what about patients with chronic pain – will those just become the new generation of opioid abusers or will their pain just not be treated at all? Currently, there are no answers to these questions.
Even though there is increased awareness, treatment options and support are still severely lacking. Not only does this result from a lack of funding, but from insufficient education of healthcare providers. A multitude of physicians are not trained to provide sufficient care for chronic pain patients. Nor can family physicians tend to a patient with a drug abuse disorder when they are lacking expertise.
According to a panel that published recommendations for tackling opioid abuse it is crucial to educate healthcare providers about alternative treatment options other than opioids. Those should only be prescribed as a last resort. The panel highlights the importance of helping patients that abused opioids for a long period and that these patients should receive a high standard of treatment to ensure success.
Multimodal pain treatments could offer a glimpse of hope to individuals with a drug abuse disorder. It consists of several treatments that together form a holistic approach tackling this disorder. Typically, this includes:
People with already existing drug abuse disorders could benefit from this approach. However, the insurance models have to be restructured so that a broad range of patience will be able to afford these programs. The authors moreover highlight that accessibility is an important factor for their success.
Howard Koh, professor of the practice of public health leadership and a member of the Stanford-Lancet Commission on the North American Opioid Crisis, also states that education of healthcare providers is inevitable to tackle this crisis. “Addiction training should be an essential part of all health professional education. The public health community can also work with the criminal justice system to move more affected people away from incarceration and towards treatment”, says Koh in an Interview with Harvard T.H. Chan, School of Public Health. He moreover states, that a way out of this epidemic of opioid abuse starts with kids and young adults. “Prevention, starting with kids, is absolutely key. We have to support stronger and more resilient children and families to address threats from opioids, tobacco, alcohol, and other substances that rob so many people of well-being.”
This crisis is far from being solved but the increasing awareness leads to a higher willingness in politicians and healthcare professionals to find a solution for those in need of help and assistance.
Image sources: Jeremy Bishop, unsplash
