As a practicing gastroenterologist, I had patients who suffered from chronic pain. I experienced how drug reps influence what brand name medications, dosages, and quantities of pills physicians choose to prescribe. I saw lazy physicians over-prescribe opioids to avoid the inconvenience of refill requests; naïve physicians over-prescribe opioids from the perspective of misguided sympathy; and unscrupulous doctors massively over-prescribe opioids for mock consultations re-imbursed in cash.
by Patrick Radden Keefe
Penguin Random House, 560 pp.
I saw patients who described chasing the euphoria some feel after a single course of medication and other patients who maintained high levels of opioid dependence (the circumstance that results in withdrawal symptoms if the drug is abruptly discontinued) without progression of tolerance (the need for progressive increases in dosage to maintain the desired effect) for years. I saw patients with addiction (compulsive drug use that continues despite harmful effects) who were trapped in a destructive cycle and others who, heroically, rehabilitated themselves.
As a member of my hospital’s medical staff leadership and as a member of the hospital board, I participated in the withdrawal of hospital privileges and revocation of licenses from physicians with substandard quality performance or their own substance abuse issues and from one family practitioner who created a pill mill (a doctor’s office engaged in the notorious practice of prescribing thousands of opioid capsules following an ersatz evaluation and a cash payment).
So when I read Patrick Radden Keefe’s Empire of Pain: The Secret History of the Sackler Dynasty, a calmly written and detailed expose of the Sackler family, Purdue Pharma, and the opioid epidemic, I was not surprised. And yet, my blood boiled.
The slippery personal morals and unprofessional ethics of the three brothers (Arthur, Mortimer, and Raymond Sackler) presaged the moral and ethical collapse of the next generation of Sacklers.
The family’s system of marketing addiction cloaked as medical treatments, first with benzodiazepines in the 1960s and then with opioids in the 1980s, was modeled after the successful tobacco companies.
In the 1950s, Arthur created the model of selling directly to physicians by drug reps using commercial marketing techniques and the endorsements of prominent doctors. By the 1960s, the Sacklers’ techniques included misleading science and massaged data from shoddy research studies that were published in minor medical journals while hiding the facts that the producers of the products, including benzodiazepines, were also the researchers, reviewers, editors, and publishers of that data.
The next generation went further in the 1980s by obscuring their ownership of Purdue Frederick (maker of MS Contin) and subsequently Purdue Pharma (maker of OxyContin). They ultimately refined the marketing process to include kickbacks to physicians and bounties to drug reps while subverting the FDA approval process. According to Keefe, they also subverted the judicial process, avoiding criminal liability and fiscal responsibility, the hallmarks of successful drug cartels in second and third world countries.
The opioid crisis unleashed by the Sacklers not only killed hundreds of thousands of patients, but it upended the lives of countless sufferers of chronic pain and the responsible physicians who were trying to care for them. Society’s response to the prescription opioid crisis has resulted in sweeping, broad brush changes that now make it harder to overprescribe pain medications. These broad regulatory adjustments lessen the likelihood that a narcotic naïve patient will be exposed to excessive dosing. But they also make it harder for narcotic dependent patients with serious illness to receive the medications that they need.
Although all pain is ultimately subjective, some painful conditions are easier to comprehend and to quantify than others. A broken leg is easier to understand than the phantom pain of an amputated limb. The pain from a shingles rash is easier to see than the chronic pain some endure years after the rash has resolved.
I viewed my patients through one of three lenses. The first included those patients with short term pain problems. These were usually patients that I saw in follow-up for bowel surgery or muscular aches and pains short of, or occasionally following, orthopedic fractures. These patients needed monitoring to prevent long-term overtreatment.
The second were patients toward the end of their lives with measurable illnesses who needed pain medications (palliation) for pre-terminal or terminal illnesses. The pain of metastatic cancer or multiple compression fractures of the spine from the osteoporosis associated with terminal Parkinson’s Disease needed adequate and accessible treatment. In these cases, potential dependence was not a great concern. These patients’ lives were irremediably unsettled by chronic illness and pain, and accessible treatment meant that copious amounts of medicine could be easily obtained and sustained without struggling through regulatory hurdles.
The third set of patients were those with pain from an unmeasurable illness. In these cases, I frequently needed expert assistance. One of my long-term patients who suffered from severe constipation was a successful Washington lobbyist. After many years of a professional relationship, he developed severe post-herpetic neuralgia (the nerve pain that persists after the shingles rash has resolved). He required non-narcotic medications for nerve pain (antineuralgics like pregabalin – brand name, Lyrica) and narcotics (a fentanyl patch and oxycodone tablets) to make it through the day. He and I worked closely with a pain management expert to minimize the pain, optimize the medications and bowel function, and mitigate the impacts of his illness on his career.
But without knowing him as well as I did, and without the guidance of his pain doctor, I would have struggled with some of his behaviors that bordered on addiction and abuse.
Physicians, in general, need more training about narcotics, better self-policing of rogue practitioners by medical staff leaders, and better credentialling of pain management experts by professional organizations (e.g., American Academy of Hospice and Palliative Medicine, American Board of Pain Medicine, American Society of Anesthesiologists). Responsible physicians who are experts (board certified) in their fields of pain management, hospice care, and palliative care need fewer government regulations to control the flow of prescription narcotics through their practices (although I endorse continued oversight of suppliers, distributers, and mega-pharmacies). Finally, we, general clinicians need to consult more regularly with our expert colleagues, funneling difficult cases, in person or via telemedicine, through pain managers, thereby improving oversight and expediting care.
As the spearhead of the destigmatization of opioids, the Sacklers have caused enough destruction. Let’s not allow them to complicate more lives.
