Painkiller Pill Mills and Corporate Responsibility

Imagine you were a manufacturer of powerful opioid painkillers and your sales representatives discover suspicious activities at the offices of some physicians who prescribed your product. These activities include patients lining up to pay cash for prescription opioids, drug deals going down in the parking lot, people falling asleep from opioid intoxication in the waiting room and physicians being visibly intoxicated themselves. In response would you:

(A) Report these doctors to the authorities?
(B) Insulate yourself by not sending your representatives to these doctors anymore, but continue to pocket the huge profits they generate from writing countless prescriptions for your products?
(C) Keep a secret list of these doctors but publicly promote the idea that painkiller abuse is not driven by wayward doctors but by other sources, such as pharmaceutical robberies?
(D) Reveal the list of doctors to authorities years later only because at that point it could stop a competitor from introducing a new generic medication that might cut into your own sales?
(E) A combination of B, C and D, but certainly not A.

According to Scott Glover and Lisa Girion of the L.A. Times, Purdue Pharma chose option E and thereby preserved its astounding profits from Oxycontin. The company’s lawyer claims that no one would be interested in their list of suspicious doctors, but immediately after the story broke state legislators understandably called on Purdue to turn over the list to the authorities.

Purdue thinks their judgement of what names should and should not release is above reproach, but:

Andrew Kolodny, a New York addiction doctor who is leading an effort to curb narcotic painkillers, said such decisions should not be made by a pharmaceutical company.

“That judgment needs to be made by state medical boards, not a corporation that benefits from overprescribing,” he said. “Purdue should make the list available to state medical boards so that physicians on the list can be investigated.”

Purdue Pharma’s conduct may seem shocking in light of the fact that it was fined $600 million in 2007 for deceptively marketing Oxycontin and understating its addictiveness. But it’s all relative. OxyContin is a multi-billion dollar profit center for Purdue Pharma, and a fine that size is therefore just the cost of doing business rather than a significant deterrent to further unethical behavior.

Comments

  1. Josh G. says

    Sorry, but drug regulators have already proven they can’t be trusted to handle this issue in a compassionate and appropriate manner. The DEA considers anyone who receives chronic pain medication to be an abuser, regardless of medical justification.

    I would far rather have a situation where anyone who wants pain medication gets it, even if they *choose* to abuse it, than a situation where people who actually are in desperate pain are unable to obtain the relief they need because all the doctors are afraid of going to jail if some bureaucrat second-guesses their medical decision.

    • Laertes says

      I wear a little device that gives me a tiny electric shock any time I begin a sentence with the word “sorry.” It’s made me about 40% less likely to sound really snotty.

        • Libertarian Fairy Killer says

          Irony is that in his more perfect world of *to thine own self only*, Rush Limbaugh would have overdosed by now.

          The bit about doctors suffering because of bureaucrat second-guessers deserves only a hearty snort of contempt. Most doctors in the US became doctors not because it was in their calling (i.e. they were natural empaths and healers) but because of the promised pot of gold at rainbow’s end. Ergo they function more as Lairds overseeing their own bureaucratic fiefdoms than true healers. To pretend that these doctors are hamstrung from prescribing pills in the most overly medicated nation on earth by government bullies? That’s a lot like pretending we didn’t go to the moon in 1969. I’ll think I’ll save my anti-libertarian fairy dust for a more *sensible* post.

          • buddy says

            Who said anything about doctors suffering? Get off your high horse and read the response.
            To your point that doctors are not hamstrung, I happen to know that they are.

          • Josh G. says

            I don’t really care what the doctors’ motives are. What I do care about is that in this instance, at least, the doctors have some incentive to provide what their patients need, while the drug warriors have no such incentive at all.

            If the concern is that doctors are overpaid then the appropriate solution is to train more and to cut down on unnecessary requirements, like the “residency” that is basically just a form of glorified hazing. We could also switch to a single-payer system to reduce overhead.

            But keep the DEA scum far, far away from any of this.

        • Libertarian Fairy Stomper says

          Original post: doctors are afraid of going to jail

          Response to my post: Who said anything about doctors suffering?

          It helps if you can read, just a little bit…

    • dave says

      Josh- I agree- the government was asleep at the switch while the opioid epidemic grew and took too many lives. And even now they refuse to require doctors to have education in pain care-and so doctors will continue to use opioids for migraine, arthritis, etc- medications which do much more harm then good. The moral and mental laziness of government towards people in pain is behind the opioid problem. It was only after the IOM 2011 on the cost of pain care did it dawn upon the government that the costs of opioids were too high. To see without a vision is a terrible thing- despite seeing the problems in pain care the government essentially has no vision nor plan to effectively address the problem.

    • skeptonomist says

      So no regulation of morphine, heroin or any other drugs? Addiction to prescription painkillers is a big problem now – the problem could only increase as any and all “painkillers” are deregulated. Can anyone document significant numbers of doctors going to jail because of overregulation (that is cases in which the abuse is not obvious)?

      • dave says

        The problem is not medications but greedy and ignorant doctors who refuse to learn how to treat pain responsibly- who said that opioids or drugs were the only treatments for pain- we know it was the pain specialists-who also are not very knowledgeable about pain care- who received lots of money from pharmaceutical companies who promoted opioids- despite knowing there was little evidence of their long term effectiveness for pain.

  2. Sebastian H says

    When you can’t trust the police to investigate fairly, and you can’t trust the system to react proportionally, it is more ethical NOT to report to the police than it is to report. In a gentler era if I saw someone drunk and pissing in the street, I might call the cops on him. He’d get put in the drunk tank for the night and life would go on. Nowadays I’m not going to risk that he might get shot, or that he might end up on some ridiculous sex crimes list, so I can’t do that.

    The drug enforcement regime has been attacking the norms of our society for decades. It can’t whine that the trust they’ve destroyed isn’t as trusting. We are at the point where I’d rather have the greedy corporation than the DEA.

    • Laertes says

      That’s pretty persuasive. My first reaction was that obviously they’re just being greedheads utterly unconcerned with the damage caused by their decisions so long as that damage doesn’t appear on their bottom line. Which is true as far as it goes, but isn’t the whole story. Doing the right thing for the wrong reason is still the right thing, and it’s hard to argue that bringing the DEA down on any doctor is ever the right thing to do. However wrong the doctor may be, the government can be relied upon to be even wronger.

    • calling all toasters says

      I don’t get it. This is clearly a situation where we are talking about the monitoring of doctors. I’m pretty sure they’re not going to be beaten to death in lockup, but rather be fined or have their medical licenses revoked. The idea that we should, without exception, look the other way as a society by trusting corporations to keep the situation under control seems bizarre to me.

      • says

        Pharmaceutical companies provide needed medication to society.

        Drug warriors are social parasites who take pleasure in controlling other people’s lives.

        There’s no contest who is more trustworthy.

        • calling all toasters says

          !) We’re not talking about drug warriors, we’re talking about medical boards. Oh, I’m sorry, “death panels.”
          2) Pharmaceutical companies are trustworthy? Please tell me you’re kidding.

          • says

            There are people in the medical profession who want to fight the war on drugs, and those who don’t. The former are not trustworthy. And pharmaceutical companies, for whatever problems they may have, are more trustworthy than drug warriors, who are basically some of the least trustworthy people on earth.

          • calling all toasters says

            Just so we’re clear: ANYONE (doctor or law enforcement agent or whoever) who wants to fight the war on drugs is not to be trusted. It’s almost as if you have such a strong opinion about the war on drugs that you actually can’t control your rage at any disagreement. Almost.

          • says

            That’s right, calling. The war on drugs is based on lies (along with a healthy dose of disrespect for other people’s choices and a fetish for controlling other people). So it’s very hard to favor it and have any respect for the truth.

            In contrast, it is possible to sell drugs and have respect for the truth.

          • Anonymous says

            +1 calling all toasters. Ms. Esper is unhinged and weakens the case for legalization by making us all look like raging fruitcakes.

        • MobiusKlein says

          you lost me at “take pleasure in controlling other people’s lives”

          Plus the false dichotomy. Gack.

          • says

            I think it’s perfectly clear that drug warriors take pleasure in controlling other people’s lives.

            They see their fellow citizens engaging in a bunch of choices they think are wrong. They think if we use enough police power, point enough guns at people, and ruin enough lives, we can “save” those people who are making bad choices. Behind that is the lack of respect for anyone’s desire to actually get high.

            Historically, drug wars have always been bound up with religion, which we all know is an instrument of social control. And they have been bound up with right wing authoritarianism and hippie punching. This is why. If you actually come at public policy from the standpoint that people have a fundamental right to decide how to live their own lives, you can still do harm reduction, but you can’t fight a war on drugs. The drug warrior has no respect for someone’s decision to get high. That’s where it all starts.

      • Laertes says

        It’s not about trusting corporations. It’s about not trusting the drug enforcement apparatus.

        If I see my neighbor’s kid vandalizing other houses in the neighborhood, I might be inclined to tell his parents about it. But if I had reason to believe that his dad would severely beat him as a result, I’d instead keep my mouth shut. The vandalism isn’t great, but I’d rather see some mailboxes get smashed up than the bones in that kid’s face.

        There’s no reason to trust the drug enforcement apparatus to deal justly with doctors who prescribe pain medication. They can be counted on to wreck careers and lives of the innocent and guilty alike, and leave suffering patients without treatment. You may not intend that result when you drop a dime on someone, but your good intentions achieve nothing besides letting you feel good about yourself.

        • calling all toasters says

          I guess you missed the part about “drug deals going down in the parking lot, people falling asleep from opioid intoxication in the waiting room and physicians being visibly intoxicated themselves.”
          I’m not a fan of the DEA by any means, but there are obviously doctors who have supplemented their income through criminal practices. What do you propose to do about that?

          • Laertes says

            I’m not saying there’s no problem. I’m saying that I’m not persuaded that the DEA will do more good than harm.

            What do I propose to do about it? How about we report the problem to some authority that can be counted on the deal with the problem in a reasonable way? As soon as we’ve got one, I’m game. All we’ve got right now, however, are a bunch of fanatics see a SWAT team as the solution to every problem.

            I mean, the kid smashing the mailboxes is a problem. I’m not denying that. But telling his dad about it will probably do even more harm. The more urgent problem there is for his dad to get some help and learn to control his violent temper. Once that problem is solved, other lesser problems become soluble.

          • calling all toasters says

            From the post: “Andrew Kolodny, a New York addiction doctor who is leading an effort to curb narcotic painkillers, said such decisions should not be made by a pharmaceutical company. ‘That judgment needs to be made by state medical boards’”

          • Laertes says

            Well, I started out with “the drug enforcement apparatus” and then didn’t want to cavil when you narrowed the focus to the DEA. But since you’re now standing on that as an important point, maybe we should back up a bit?

          • NCG says

            This is an attempted reply to Laertes.

            I think the missing authority figure is medical boards. Doctors may not like enforcing norms on each other, but if they don’t start, I tend to agree that legislators/DEA will give us something far worse. They’re certainly trying already.

            I don’t know who’s right about opiate alternatives, dave or someone else. But when it’s my turn to suffer, I want access to *all* options. Along with good information about them. So that that!!!

          • NCG says

            Oops, and I forgot, pharmacists ime tend to be very smart and helpful. Plus there are those computer systems. We are not without tools to attack the addiction problem, short of putting everyone in jail. We should all take a deep breath.

          • says

            From the post: “Andrew Kolodny, a New York addiction doctor who is leading an effort to curb narcotic painkillers

            I don’t trust addiction doctors. That’s a much bigger racket than anything drug companies do.

          • calling all toasters says

            Wow, you’re just full of the hate for everyone who disagrees with your little position.

        • dave says

          I don’t believe there are too many innocent doctors out there- they make 2X as their European counterparts and use much more opioids- and Europe has a better record of pain care. Doctors listened to pain specialists in the 1980′s who promoted opioid use for all kinds of pain conditions- with no long term evidence of their effectiveness. So the greedy and morally and mentally lazy doctor said gee I don’t need any education in pain care- ill just throw an opioid or anti-inflammatory at everyone who has pain regardless of addiction or in the case of anti-inflammatories- regardless if they cause ulcer. Sorry, but I don’t have much compassion for the morally and mentally doctors in America.

    • paul says

      But look what’s happening here: the doctors are in the same danger of going to jail or losing their licenses (with a slight delay), once the authorities get involved there will be plenty of patients who lose access to medication, but the only difference is that a particular company has collected a few hundred million dollars in the meantime. Oh, and the company is doing it specifically to prevent painkillers from becoming more widely available…

      • dave says

        Then call for all doctors to have education in pain care and use nonpharmacological treatments for pain. 60X as many doctors in Germany practice acupuncture. The truth here is doctors don’t like society telling them to treat pain responsibly by getting themselves education in pain care- and the government doing more or less what doctors want. It was only when government found out that opioid diversion costs over $65 billion/year did they respond-and still they refuse to require any doctors to have any education in pain care.

        • Josh G. says

          Your obfuscation, spewed over about half a dozen posts in this thread, is really tiring. You’re promoting “nonpharmacological treatments for pain” – or, to put it more honestly, telling pain patients to suck it up and deal. That is outright evil, and that is why we cannot trust drug warriors to decide who gets access to what medication.

          • Dave says

            Josh- I guess you never heard of acupuncture, microwave resonance therapy,dry needling, platelet rich plasma, stem cell therapy, biofeedback, nerve transfer, low intensity pulsed ultrasound, advanced clearning energetics, cbt- just to name a few of the hundreds of nonpharmacological treatments for pain.As the leading advocate in NYS for legislation requiring doctors in NYS to have education in pain care- I always enjoy it when people pretend to be knowledgeable- it makes it easier for me to get more legislators to sign on to legislation requiring education in pain care. Oh and by the way I actually have the best record in the country- as also all my Federal legislators are also signed on to legislation on education in pain care. Whats your record Josh? Josh- you sound like you have been captured by the false consciousness of pharmaceuticalization.

          • Dave says

            The evil lies with people pushing tired old ignorant and uncaring solutions to serious problems. They condemn without investigation alternatives and they point a finger at everyone else and do nothing to solve problems. Suffering from identity foreclosure they only serve to continue institutional persistence to the detriment of the public good. They are stuck in the reinforcing loop super stare vias antiquaries. They fiddle while people in pain burn.

          • dave says

            Which acupuncture are you referring to- Denmai, kototoma, Masakazu, silver spiked point, implant, ryodoraku,ion pump,taegeuk, manaka, tan, tung,toyohari motion style- or do you claim that all acupuncture is the same, Oh by the way acupuncture is used on race horses and other animals-do you claim it has a placebo effect on them, as well.. If tha is the case then were going beyond Newtonian physics based biomedical antipathic medicine. But my guess is youre someone who believes in Cnidian biomedical antipathic medicine-which couldnt explain placebo effects as Newtonian physics cannot explain such.

          • Alex says

            Yeah, this is supposed to be a “reality-based” community.

            I don’t know what doctors should do for chronic pain patients, but I know that the answer is “Not acupuncture.”

            My only qualifier on that is that elaborate placebos can still have real benefits, to the extent that being more calm and relaxed is a benefit. So if somebody wants a placebo, for the purpose of managing stress, and that reduced stress improves their health, great. Go for it. Whatever floats your boat.

            Just don’t call it something that it isn’t. It’s stress relief, and that’s fine. It’s performing the same role for some patients that hobbies, entertainment, sports, or whatever else fulfills for other patients.

          • Dave says

            Alex- sophistry and rhetoric not very convincing. Your opinion obviously isnt based on spending much time researching treatments in pain care-and the public good isn’t served by morally and mentally lazy people.

          • Ed Whitney says

            Ah yes, good old sciencebasedmedicine.org. Pay attention to what they do not say as well as to what they do say.

            “Large multicenter clinical trials conducted in Germany7–10 and the United States11 consistently revealed that verum (or true) acupuncture and sham acupuncture treatments are no different in decreasing pain levels across multiple chronic pain disorders: migraine, tension headache, low back pain, and osteoarthritis of the knee.”
            This is true enough as it stands; one of the referenced studies, Haake M, Muller HH et al. German Acupuncture Trials (GERAC) for Chronic Low Back Pain. Arch Intern Med. 2007;167(17):1892-1898, did indeed show that true and sham acupuncture produced similar degrees of pain relief for low back pain, showing that “acupuncture is just a placebo.” What sciencebasedmedicine does not tell you is that Haake et al did not just randomize participants into two groups, true and sham acupuncture; they randomized patients into three groups, two of which involved acupuncture and one of which was standard therapy; this group received multimodal treatment program according to German evidence-based guidelines; it included 10 meetings with a physician or physiotherapist who administered PT, exercise, and such; 95% took analgesics.

            A “response” was predefined according to changes in a standardized pain and function questionnaire, and the main outcome was measured at 6 months. A “response” was recorded in 47.6% of true acupuncture, 44.2% of sham acupuncture, and 27.4% of conventional care.

            So the two acupuncture groups had equal efficacy as measured by the outcome scores; the conventional care group had a much lower response rate. The sciencebasedmedicine group focuses on the first two response rates, sees that they are equal, and declares that acupuncture is bunk; if this is so, then the German guidelines for chronic low back pain, consisting of the interventions which pass muster with sciencebasedmedicine.org, are even greater bunk. Most randomized trials of this topic have compared two treatment groups, consistently finding that any differences between true and sham acupuncture are clinically unimportant; Haake et al compared three groups, and thereby raised questions in which sciencebasedmedicine.org has no interest whatsoever.

            The functioning of the RBC website depends upon the ability of supposedly educated persons to read. I hope that no one will infer that I am a true believer in acupuncture; I am simply a critical reader of sciencebasedmedicine.org when it comes to acupuncture.

          • Ed Whitney says

            True enough, David. Opioids for chronic pain are a generally bad deal, and are suspected of being counterproductive in many cases, especially for neuropathic pain.

            Many of the sham-acupuncture controlled studies have the sham acupuncture administered by trained acupuncturists who place the needles away from the classical acupuncture points but do not place them at random or without any skill; that is, the studies do not get the guy from the stock room to do the control procedure. Why don’t they, if acupuncture really does nothing? There is a difference between having a trained acrobat go out and act like a klutz, and having a klutz go out and act like a klutz. Some of the skill of an experienced performer will carry into the former performance but not the latter. This also is not something that the folks at SBM are interested in considering.

          • dave says

            Ed- point well taken. A book on Pain and Placebo recently came out and i think placebo response can be explained from a quantum viewpoint. With regards to acupuncture, of course holding a metal object close to the body can effect the bodies electromagnetic field. So the word “sham” betrays an understanding of how the bodies electromagnetic field can be changed without touching the body. In acupuncture such as Denmai style, techniques are used where the needle just touches the active points without insertion. A similar thing is done in network chiropractic with the hands and in craniosacral therapy. With regards to pain medications experts like Denis Turk-who took part in the IOM’s 2011 report on pain care in America have indicated our best treatments for pain are 30% effective. So there a lot more to be done when it comes to finding and testing treatments for pain.

          • Alex says

            dave, if you have evidence that acupuncture works in clinical trials, great. But your babble about quantum mechanics and electromagnetic waves hurts the ears of this physicist.

          • Dave says

            Alex- et tu Brute. You have yet to add anything “material” to the discussion. Some conjugate phase adaptive resonance may help to synchronize your thalamocortical dysrythmia- but i digress perhaps its a problem of holographic correspondence- a veitable bilateral interhemispheric transfer defect- dont worry Ill create a primary torsion field to neutralize your neutrinos. Oh by the way Alex try saying something material next time.

  3. Sebastian H says

    Unfortunately, you’re wrong. The move to treat pain management docs as potential drug dealers has been going on a while. See for example Radley Balkos http://m.huffpost.com/us/entry/1240722

    There are better articles by him but I don’t have lots of time today. Google his name and pain management.

    • Sebastian H says

      I apparently misused the reply feature. The above comment was regarding the idea that doctors weren’t at risk of going to jail over this.

  4. James Wimberley says

    Is $600 million in fines and civil penalties really insignificant? It covers the period 1995-2001, when total sales of (not profits on) Oxycontin were $2.8 billion. The typical industry gross profit margin is given by the WHO as 30%, which would give Purdue´s profits on the drug at around $900m. It was probably more as the industry average includes less successful drugs as well as blockbusters. Still, the fine must have clawed back somewhere between one-third and two-thirds of the profits made.

    Purdue and its managers also unusually pled guilty to criminal charges: a corporate felony and three individual misdemeanours of misbranding. The three managers paid $34.5 million in personal fines. That looks deterrent, if you add the career-ending aspect of a criminal conviction.

    Since SCOTUS thinks corporations are people, perhaps convict ones should lose their right to ¨vote¨ through political contributions.

  5. says

    Corporate fines do nothing whatsoever to change behavior because the persons making the decisions are untouched. If we wish to change corporate behavior, corporate executives must be held personally responsible and, when appropriate, serve prison time. So long as the only punishment is cutting a check, misbehavior will continue. But put a CEO in prison and behavior would change quite rapidly and dramatically.

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