This summer, a sculptor built a steel, 11-foot, 800-pound bent heroin spoon. With the help of an gallery owner, he put it on a trailer and drove it to the headquarters of Purdue Pharma, the manufacturer of OxyContin.
The bent-spoon protest of the country’s opiate epidemic by Massachusetts sculptor Domenic Esposito and Fernando Alvarez, owner of a Connecticut art gallery, stayed in front of the company’s Stamford, CT offices for only two hours before police impounded the sculpture, but it gained worldwide attention.
Alvarez was arrested and eventually convicted of a misdemeanor charge of blocking free passage.
I was in Boston recently and had a chance to meet and talk with Esposito about the episode and what brought it on.
Our conversation ended up including his brother’s addiction, drug marketing, Americans’ pain, and #thespoon movement they hope to ignite.
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From 2006 to 2015, Dr. Michael Rhodes was one of the top prescribers of OxyContin in the state of Tennessee.
His practice had many of the signs of what had come to be called a “pill mill.” Lines of people outside. A knife fight in front of his office. Investigators found he often prescribed without proper physical examinations or knowing the medical histories of his patients. Over those years, Rhodes, of Springfield TN, prescribed 319,000 OxyContin tablets. In May, 2013 had his license placed on restrictive probation by the Tennessee Board of Medical Examiners.
Still, representatives from drug-maker Purdue Pharma continued to call on him urging him to prescribe more OxyContin, their signature drug, according to a lawsuit filed by Tennessee Attorney General Herbert Slatery.
“In spite of this disciplinary action by the board (of medical examiners) and direct knowledge of his patient’s death from OxyContin, Purdue continued to call on Dr. Rhodes,” the Tennessee complaint states. They continued to “pressure Dr. Rhodes to prescribe more and more opioids, even when he expressed concerns regarding his own ability to competently do so.”
According to the lawsuit, Purdue reps called on Dr. Rhodes 126 times, include 31 times after his license was restricted.
They did so during the years after the company signed an agreement in 2007 with the federal government to be vigilant for abuse and diversion of the pills and look out for doctors prescribing in unscrupulous ways.
Part of the Tennessee complaint against Purdue catalogues alleged attempts by the company to get high-prescribing doctors and nurses to prescribe even more of their product, despite signs that those medical professionals were behaving in unethical ways and that their prescribing habits were out of control. Cultivating high-volume prescribers, the complaint alleges, was seen as crucial to the company’s business. The complaint alleges the company called on several such nurse practitioners, three now-shuttered pain clinics, and 13 doctors, who’ve retired or had their licenses revoked or placed on probation.
Among them was Dr. James Pogue, of Brentwood, TN, who prescribed 562,000 OxyContin 80mg pills between 2006 and 2013, making him one of the largest prescribers in Tennessee even three years after he stopped practicing medicine. He generated $655,000 in revenue for the company during one six-month period in 2009, according to the complaint.
Company sales reps called on him 53 times between 2005 and 2012, “more than half of those occasion coming after his license was reprimanded in 2009.”
The Breakthrough Pain Therapy Center, in Maryville TN, was known to have none of the typical diagnostic tools associated with pain clinics: examination tables, gloves, urine screens “or providers who performed independent pain diagnoses.” It also included “scant” office records and pre-written prescriptions often dispensed “without a physician present.”
While placing some staff on no-call lists, the complaint claims Purdue continued to call on other staff members at Breakthrough Pain Therapy, whose owners were federally indicted in December 2010. This included Buffy Kirkland, a nurse practitioner who worked there for several years. Between 1998 and 2017 as a nurse practioner in Tennessee, she prescribed 68,000 OxyContin tablets, of which two-thirds were of 40mg or stronger, according to the complaint.
The Tennessee complaint is one of numerous lawsuits filed in the last year or so against Purdue and several other drug companies that make opioid painkillers. The plaintiffs include Native-American tribes, small towns like Everett, WA and large cities like Los Angeles and Chicago. Most state attorneys general have filed lawsuits, as have at least 300 counties in a suit that alleges a “public nuisance” by these companies. That suit is consolidated in a federal court in Cleveland.
When I was writing Dreamland in 2013-14, I remember only three such lawsuits against makers of opioid painkillers. This was a time when the issue was largely hidden, those affected largely silent. Families were ashamed and wanted to obscure the truth of the addiction and manner of death of their loved ones. Thus the media paid scant attention and elected officials, outside those in a few states, paid less.
But the awareness has expanded in the last three years. One result is that many more lawyers across the country have turned to examining legal theories that might prosper in court.
Public agencies have been hammered by the cost of the epidemic. Indeed the epidemic’s costs have largely been borne by the public — by coroners and public health offices, police and sheriffs departments, jails, county hospitals, foster children agencies and more. Meanwhile profits have largely accrued to the private sector, mostly to pharmaceutical companies.
Thus, today, most state and county officials have to be seen by their constituencies as doing something dramatic about this epidemic, and a lawsuit has become an option to recoup some of those costs. None of the new lawsuits has yet gone to court.
“Always Be Closing” is the motto that salesmen live by in the movie/play Glengarry Glen Ross.
If you haven’t seen the movie, do so. It’s great: Al Pacino, Jack Lemmon, Alex Baldwin, Kevin Spacey. It’s about an office of desperate sales guys hawking shady real estate investments. ABC — “Always Be Closing” — is the way each is supposed to approach every sales call.
The suit was filed in May by the office of Tennessee Attorney General Herbert Slatery. It alleges a lot of things, but in general that Purdue used deceptive marketing practices to push its signature drug, OxyContin. This took place, the suit alleges, between 2009 and 2012, well after the company and three of its executives pleaded guilty (in 2007) to a federal misdemeanor of false branding and paid a $634 million fine, while also committing to a series of measures to ensure they were not marketing to doctors who were prescribing unscrupulously.
The company moved to seal the lawsuit, but a judge in Knoxville recently decided against that idea, allowing the office to send me, and others, a copy.
In general terms, what I find interesting the lawsuit is how it displays the changes in pharmaceutical sales in this country, much of that coming during the life of OxyContin, though not due to it.
Up to the mid-1990s, drug salesmen in the United States were usually older men, often with backgrounds in pharmacy or medicine. They were often from the communities they sold to, knew the doctors they sold to, and became credible sources of information for those same doctors as medicine began to change rapidly.
Then the industry went another route. Those older folks were shown the door. In what can be called a sales force arms race, drug companies hired more and more reps. These reps were usually much younger, very good looking. They didn’t know much about they were selling but they have backgrounds in sales. They inundated doctors with visits and giveaways, of pens, calendars, lunch, sometimes trips for continuing medical education seminars. The companies were aware that by massaging a doctor’s staff, the doctor would soon be an easier mark.
Many companies did this. The numbers of sales rep rose through the 1990s from 35,000 nationwide to over 100,000 by the end of the decade. But other companies were selling blockbuster drugs to deal with cholesterol, hypertension and others. Purdue was among the few that used these techniques, and this enhanced salesforce (numbering eventually 1,000), to sell a narcotic painkiller.
“Always Be Closing” was, apparently, part of that push at Purdue. So, allegedly, was mention of the movie. All of this coming after the 2007 criminal lawsuit.
In Tennessee, (pop. 6.6 million people), the company made 300,000 sales calls to health care providers in the 2007-17 decade, during which time doctors prescribed more than 104,000,000 OxyContin tablets; more than half of those tablets were at the strongest doses the company made: 40mg and above.
Those of you who’ve read my book Dreamland know that, to me, supply is the crucial factor in this, and really in any drug scourge. What the lawsuit describes is a company hard at work at creating a vast new supply of opioids.
Company instructional materials pushed sales folks to “expand the physician’s definition of the appropriate patient” to which opioids might be prescribed; to “never give someone more info than they need to act”; and to develop a “specific plan for systematically moving physicians to move to the next level of prescribing.”
“We sell hope in a bottle,” said one guide for incoming salespeople, who were also instructed to encourage doctors to increase patients’ daily doses.
The lawsuit goes on to claim that Purdue sales reps in Tennessee were urged to make frequent sales calls, as evidence showed that that increased the number of prescriptions. According to the lawsuit, the company urged its salespeople to “focus on doctors who had more patients, less likely to have pain management expertise, and have less time to appropriately monitor patients on opioids.”
During these years, Purdue sales reps, according to the lawsuit, focused their efforts on primary care doctors, nurse practitioners and physicians assistants, whom the company “knew or should have known … had limited resources or time to scrutinize the company’s claims.” Together, people in those three profession prescribed 65 percent of all OxyContin tablets in Tennessee during these years. By 2015, Tennessee had the third highest prescription rate of opioids in the country.
A major part of the lawsuit goes on to discuss specific examples of Tennessee doctors who were leading the state in opioid prescribing, often with signs that their practice was out of control or they were incompetent or unscrupulous, yet who were nonetheless aggressively marketed to by Purdue salespeople.
I continue to receive letters from parents whose children have been consumed in America’s opiate epidemic. Here is one:
Your book, Dreamland, does an excellent job of outlining how the convergence of the pharmaceutical environment with heroin trafficking from Mexico over the last two decades provided the avenue for the addiction that killed my son. I believe his story is the third leg of your book.
Sam was born in 1994. The next year, OxyContin was approved. Sam was a sweet toddler when Purdue began its aggressive and misleading marketing campaign for the drug. Meanwhile, Sam’s dad was writing a masters thesis on heroin production in Colombia — it was becoming so pure, he pointed out, that it could be snorted or smoked, avoiding the stigma of needles and making its way into the mainstream.
By 2000, when Sam was six and entering first grade, revenues from OxyContin had quadrupled. The initial 80 mg pill had given way to a 160 mg pill to account for increasing tolerance among patients. Purdue’s sales force had doubled and salespeople were receiving annual bonuses of $70,000 and above.
In 2001, when Sam was seven, Purdue was spending $200 million in marketing and had pinpointed doctors who tended to prescribe lots of pain medication for aggressive marketing campaigns. Sam began to face some bullying in school.
By 2002, Purdue knew of doctors who were recklessly prescribing its drug. Sam continued to struggle to fit in at school. It began to affect his mood and motivation.
Between 1999 and 2010 (the year Sam turned 16) Oxycontin prescriptions and overdose deaths quadrupled. Swapping pills became the new form of partying in the schools. Sam found a way to fit in and feel good all at once.
Meanwhile, heroin from Mexico had been making its way north, poised to fill the gap when opioid pharmaceuticals became harder and more expensive to obtain. Sam found his way to that solution.
My beautiful and beloved son, Samuel Logan Chappell, died of a heroin overdose in Columbus, Ohio, on Sept. 7, 2015.