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Throughout OxyContin’s earliest years, only a few voices of dissent rose to remind doctors that, historically, there had been risks associated with prescribing narcotics, and even those warnings were timid. Dartmouth medical school substance abuse researcher Dr. Seddon R. Savage argued that addiction risks for pain patients on narcotics tended to increase the longer the patients used the drugs. “It is tempting to dismiss all concerns regarding therapeutic opioid use as irrelevant,” she wrote in a physician journal in 1996. “That would clearly be a mistake.” A colleague argued in the same paper that there simply wasn’t enough good data available to make a case for or against liberal opiate prescribing.
The first real dissent would come soon, though, in the unlikely form of a country doctor and one thoroughly pissed-off Catholic-nun-turned-drug counselor. Though Dr. Art Van Zee and his colleague Sister Beth Davies would sound the epidemic’s first sentinel alarm from Appalachia, they were greeted with the same indifference as the Richmond doctor who demanded prompt action to curb the rampant use of opioids in 1884, and the inventor of morphine, who strongly urged caution in 1810. Their outsider status disguised both the depth and the relevance of their knowledge.
Evidence room, Lee County Sheriff’s Office
Chapter Two
Swag ’n’ Dash
Around the time the Big Stone Gap informant was leaning into the police officer’s cruiser, the FDA loosened rules on pharmaceutical ads, allowing drugmakers to air detailed television ads touting specific medical claims for nonnarcotic drugs. Drug advertising ballooned from $360 million in 1995 to $1.3 billion in 1998, and nearly all pharmaceutical companies spent more plying doctors with freebies. At a time when there were scant industry or federal guidelines regulating the promotion of prescription drugs, the new sales strategies pushed the narrative of curing every ill with a pill and emboldened many patients to seek medicines unnecessarily.
From a sales perspective, OxyContin had its greatest early success in rural, small-town America—already full of shuttered factories and Dollar General stores, along with burgeoning disability claims. Purdue handpicked the physicians who were most susceptible to their marketing, using information it bought from a data-mining network, IMS Health, to determine which doctors in which towns prescribed the most competing painkillers. If a doctor was already prescribing lots of Percocet and Vicodin, a rep was sent out to deliver a pitch about OxyContin’s potency and longer-lasting action. The higher the decile—a term reps use as a predictor of a doctor’s potential for prescribing whatever drug they’re hawking—the more visits that doctor received from a rep, who often brought along “reminders” such as OxyContin-branded clocks for the exam-room walls.
The reminders were as steady as an alarm clock permanently set to snooze. Purdue’s growing legion of OxyContin apostles was now expected to make more than a million calls annually on doctors in hospitals and offices, targeting the top prescriber deciles and family doctors, and aggressively promoting the notion that OxyContin was safe for noncancer patients with low back pain, osteoarthritis, and injury and trauma pain.
The practice became standard in rural Virginia towns like Big Stone Gap, Lebanon, and St. Charles—places that already claimed higher numbers, per capita, of dislocated workers and work-related disability claims. Now Purdue reps were navigating the winding roads and hilly towns in company-rented Ford Explorers, some pulling down annual bonuses of $70,000—the higher the milligrams a doctor prescribed, the larger the bonus. And they were remarkably adept. Five years earlier, cancer doctors had been by far the biggest prescribers of long-acting opioids, but by 2000 the company’s positioning goals had been nailed, with family doctors now the largest single group of OxyContin prescribers.
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Industrywide, pharmaceutical companies spent $4.04 billion in direct marketing to doctors in 2000, up 64 percent from 1996. To get in the doctor’s door, to get past the receptionist and head nurse, the reps came bearing gifts, from Valentine’s Day flowers to coupons for mani-pedis.
The average sales rep’s most basic tool was Dine ’n’ Dash, a play on the juvenile-delinquent prank of leaving a restaurant without paying the bill. For a chance to pitch their wonder drug, reps had long offered free dinners at fancy restaurants. But soon, to-go options abounded, too, for a busy doctor’s convenience. Reps began coming by before holidays to drop off a turkey or beef tenderloin that a doctor could take home to the family—even a Christmas tree. Driving home from the office, doctors were also invited to stop by the nearest gas station to get their tanks topped off—while listening to a drug rep’s pitch at the pump, a variation the reps nicknamed Gas ’n’ Go. In the spring, the takeout menu featured flowers and shrubs, in a version some dubbed—you guessed it—Shrubbery ’n’ Dash.
There seemed to be no end to the perks, or to the cloying wordplay: At a bookstore event titled Look for a Book, an invitation issued by SmithKline Beecham asked doctors to “come pick out the latest book about your favorite hobby or travel destination!” Purdue reps were heavily incentivized, buoyed by $20,000 cash prizes and luxury vacations for top performers and a corporate culture that employed terminology from the Middle Ages to pump up its foot soldiers. Internal documents referred to reps as royal crusaders and knights, and supervisors went by such nicknames as the Wizard of OxyContin, the Supreme Sovereign of Pain Management, and the Empress of Analgesia. Purdue’s head of pain care sales signed his memos simply “King.”
Physicians willing to submit to reps’ pitches were routinely given not just branded pens and Post-it notes but also swing-music recordings labeled “Swing in the Right Direction” and freebie pedometers with the message that OxyContin was “A Step in the Right Direction.”
A chain-smoking doctor in Bland, Virginia, was so blatantly in favor of graft that she posted a signup sheet in her office, soliciting reps to sponsor her daughter’s upcoming birthday party at Carowinds, an amusement park—and one (not a Purdue rep) did. She even accepted cartons of cigarettes emblazoned with a sticker for Celexa, the antidepressant manufactured by Forest Laboratories: another gift from another clever rep.
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Steve Huff was in medical residency training in the mid-1990s when he sampled his first taste of pharmaceutical swag—and not just by way of stickers, golf balls, and pens adorned with drug company names. “We were impressionable young doctors, fresh meat with a lifetime of prescribing ahead, and they flocked to us,” he told me. “They took us golfing. It was standard to have a free lunch most days of the week because the drug companies were always buying, then you’d have a short educational seminar going on [about their drugs] while you ate.”
By the time he progressed to a family practice, Huff decided the free meals were wrong and said so repeatedly, making a show of retrieving his cold leftovers from home from the office fridge, he told me. When he set about trying to coax the other doctors in his practice to ban the lunches, they demurred, saying the staff would be so disappointed if we “took away their free meals,” Huff said.
The reps tended to be outgoing, on the youngish side of middle-aged, and very good-looking. “They were bubbly, they’d flirt a little bit, and it really would make you feel special. And yet intertwined in all those feelings is the name of a drug, which the rep is repeating over and over while you’re eating this delicious, savory meal. And even if you say you’re not swayed by such things, there is no doubt in my mind that you’re more than likely to prescribe it,” Huff added.