After his prominent documentaries ‘Going Clear: Scientology’, ‘Agents of Chaos’ and the recent ‘The Inventor: Out for Blood in Silicon Valley’, the Oscar winner Alex Gibney picks up another uncomfortable topic: the opioid crisis. Although it seems like the subject has already saturated the news so that we have normalized the innumerable deaths from opioid overdose, there are many aspects that make this 2-episode documentary worth watching. And it is almost like watching a crime happening in front of our eyes.
Part One “focuses on how Purdue worked closely with the FDA to get the highly profitable pain medication approved for wider use, promoting its safety without sufficient evidence, and creating a campaign to redefine pain and how we treat it.”
Purdue Pharma hit the jackpot. The pharmaceutical company that gained notoriety over the last twenty years selling their opioid-based blockbuster drug OxyContin (OC) did what most highly organised drug cartels do: they got the American population addicted to pain relief, hooking them on high doses of opioids in order to “get their life back”. The only difference was that they did it with FDA approval. And on a much bigger scale.
The Sackler family (currently the 30th richest family in the US) bought Purdue in 1952. At the time the small pharmaceutical company was known for producing earwax and laxatives. But Arthur Sackler, the mastermind of the modern pharmaceutical marketing, and his two younger brothers, Mortimer and Raymond, had big ambitions to transform its image.
In 1984, after Arthur‘s death, the brothers brought their first big drug to the market: MS Contin. It was a dose of morphine in an innovative coating that allowed a slow release of the drug over 12 hours. For the patients it meant that instead of having to take a pill every few hours and fear that the pain might suddenly return, they could trust that medication to continuously bring them relief for most of their day.
But doctors were not eager to prescribe morphine to regular patients suffering from moderate pain, for fear of addiction. The predominant belief in the medical field was that pain is an indication of an underlying physical condition, and its cause should be treated, rather than the symptom. Purdue decided to change that. They put oxycodone, an opioid similar in action to morphine but with less stigma attached to it, into the same kind of coating for extended release and in 1996 marketed it as OxyContin. To convince the doctors that this time the drug was safe to prescribe, they hired an army of sales representatives.
Helping under-treated pain patients “get their life back”?
The Purdue sales representatives were trained to believe that there is a great problem with undertreatment for pain in the population because doctors were afraid to prescribe strong painkillers; opioids were mostly reserved for cancer or seriously injured patients. Thus, promoting OxyContin was an honorable and honest thing to do to help those undertreated pain patients to “get their life back” and restore the quality of their lives. The more doctors they convinced of the same, the more bonuses they would get. Pretty soon the business was booming.
In the 1990s the demand for raw opium grew so fast that Purdue’s supplier, Johnson & Johnson, developed genetically modified opium plants that would contain more thebaine, the precursor used to manufacture oxycodone, and find a more effective harvesting method for their farming fields in Tasmania in order to meet the demand. In 2000, Purdue sales from OxyContin reached 1 billion dollars; 40 million of which was solely spent on bonuses for the sales reps.
Even when the doctors raised concerns about the increasing rates of opioid addiction in the population, especially in the rural parts of the country, the company still claimed that less than 1% of patients on opioids become addicted, and those seeking pain relief cannot be considered to have developed an addiction in the same way that people outside of a medical context can. Purdue described this behaviour as “pseudoaddiction” and advised the doctors to simply increase the dose of the prescribed opioid. They were told repeatedly the disclaimer from the drug’s insert that “delayed absorption of oxycontin is believed to reduce the addiction potential”. None of the Purdue’s officials thought that the OxyContin’s slow-release coating can be easily bypassed by simply crushing the pill and injecting it to produce a heroin-like high.
Fentanyl usually appears in the news as an extremely deadly street drug, described as 100 times more potent than morphine. The truth is however that fentanyl was first widely introduced legally, primarily in the form of a lollipop Actiq by the company Cephalon, and in 2012 by Insys Therapeutics with their innovative sublingual spray Subsys, that was approved by the FDA exclusively for adult patients that were already using opioids, for treating breakthrough cancer pain.
But, as an investor, John Kapoor, the founder of Insys, was not focused on pain, but on profit. With his sales team, following the Sacklers’ example, they hired attractive, eloquent sales representatives who would bribe doctors with “speakers fees” offered in exchange for prescriptions. Insys would even set up a special call centre where operators had to convince the insurance companies that the patient needs such a strong and expensive (the lowest dose of Subsys, 100 mcg, costs on average 74,35$ per unit, the strongest one 800mcg – 244,31$) pain medication and their job was to imply that the patient has cancer, although in most cases they didn’t.
As Long As There is Profit In It
The creators of The Crime of the Century have put a great deal of effort tracking the causes of the opioid crisis and explaining why it was possible for the pharma industry to take advantage of the legal loopholes and bribes to increase their sales, how this led to the emergence of “pill mills”, operated in some states that were solely focused on selling opioids to anyone and what tricks were used to convince the doctors to prescribe more, or silence the ones who were warning about the raising addictions. Many of those methods are described by the whistleblowers and former sales representatives themselves.
Beyond reporting such crimes, the documentary reveals the schemes and frameworks that allowed those abuses to happen and how the systemic place to prevent them easily fails. They not only blame the pharmaceutical companies for conspiring for capitalist gain and doctors for overprescribing strong pain medication, but also the members of Congress and politicians for enabling them to do so.
It features many prominent figures that speak on the opioid crisis, such as Barry Meier, a journalist who highlighted the developing addiction problem of prescription opioids in his 2003 book “Pain Killer”, and Patrick Radden Keefe whose book “Empire of Pain” is the latest account of the opioid overdose epidemic, Joe Rannazzisi, a former DEA agent who rang the alarm on the danger of fentanyl and diversion of prescription opioids.
We witness court hearings of Purdue’s officials, many of them released for the first time, who at any point wouldn’t acknowledge any wrongdoing. It is a tough account of how the approach that “the drug isn’t the problem, the user is the problem” shifts the responsibility of addiction to the patient.
In a way, the documentary provides an insight into how easily we can close our eyes to harm, as long as there is profit in it. Perhaps the very root of the opioid crisis is human greed. The party line – pretending that things were fine – looked profitable for everyone.
Why Aren’t The Sackler Family Being Held Responsible?
The CDC estimates that nearly 841,000 people have died since the 1999 from a drug overdose. The number of deaths from opioid overdose increased 6-fold since the same year. The effects of the COVID-19 pandemic on the overdose crisis highlighted the scale of the problem even more, as together with the growing unemployment, some states registered a spike in the deaths from opioid overdoses in the first months of the pandemic.
Additionally, the pandemic caused some of the support centres for recovering opioid users to close, which in turn caused many of them to relapse due to lack of support and structure and additional uncertainties arising from the pandemic.
Although we have witnessed the opioid pandemic for over a decade, there is one important point to make out of it: if these documentaries are still being produced and are still shocking, uncovering more and more layers of the conspiracy, it means that the opioid crisis is still far from being resolved.
The Crime of the Century doesn’t give an answer how to deal with the opioid crisis, but it underlines the fact that letting Pharma and Healthcare be managed by the rules of capitalism and profit might not be the best idea. Patrick Radden Keefe in his follow up article highlights a quite vivid disparity: if we punish with 15 years of prison a person that gave to his friend fentanyl thinking that it’s heroin, which caused him to overdose, why aren’t we holding the Sackler Family responsible for causing the death of thousands of people?
The series just briefly describes the most recent developments on the case, including the company filing for bankruptcy in 2019, after years of selling one of the most profitable drugs in the history, and the 2020 settlement where Purdue Pharma pleaded guilty to some of the charges. Before that Sacklers managed to move millions of dollars out from the company to their private accounts. None of family members was personally prosecuted.
You can watch “The Crime of the Century” (presented in association with The Washington Post) on HBO and HBO GO streaming platforms.