Laura Sophia Hauck
Max-Weber-Institut für Soziologie
For years, cancer has topped the list of leading causes of death among people aged under 55 in Germany, while in the U.S. it is overdoses resulting from abuse of opioid painkillers. Over the past two decades, their use has become an epidemic; an addiction wave that claims more victims every year. For example, in 2019 alone, approximately 70,260 people in the U.S. died as a result of opioid overdoses, two-thirds of which were from prescription drugs.
The best-known active ingredient – and “kickstarter” of the crisis – is oxycodone, marketed under the trade name Oxycontin by the company Purdue Pharma. Although Purdue was not the only manufacturer of opioid painkillers, the company played a significant role in the emergence of the opioid crisis due to its particularly aggressive marketing strategy and lobbying. The promise of “quick and easy pain relief” thus turned into one of the biggest health crises in the USA, with some 450,000 deaths to date.
The opioid crisis in the US
When Purdue Pharma launched its drug Oxycontin in 1996, opioids were prescribed only very hesitantly and almost exclusively to those who were seriously ill and in palliative care because of their highly addictive potential. The company changed this practice through, among other things, pseudo-serious informational videos, supposedly scientific studies with which they downplayed the risk of addiction, and the payment of kickbacks. The target audience for these marketing efforts were physicians, who subsequently began prescribing high-dose opioids even for everyday and chronic pain. This was also made possible by the company’s intensive lobbying efforts, which led to coverage by health insurers. This was a resounding success for Purdue and many other manufacturers, as ever higher doses are needed at ever shorter intervals to achieve an analgesic effect over an even longer period of time. And higher doses mean a rapid increase in sales and greater profits. In 2000, for example, almost 6 million prescriptions were written for the drug. Overall, Purdue generated sales of $35 billion with Oxycontin by 2017, making it at times one of the top-selling drugs in the world.
The legal disputes
However, a wave of lawsuits in the wake of increasing addictions followed quickly. Back in 2007, Purdue paid $634 million in connection with its role in the opioid crisis but did not abandon its advertising and sales strategy. As revealed in out-of-court settlement reached earlier this year by consulting firm McKinsey and 49 U.S. states, between 2004 and 2019 the company supported or “turbocharged” Purdue’s marketing of Oxycontin – long after the company pleaded guilty for misleading the public about the risk of addiction in 2007. According to the documents, McKinsey seemed to have recommended promoting the high-dose opioid drug in particular and working with other opioid manufacturers to fend off “strict treatment” by the FDA. During the investigation into Purdue – which also dealt with McKinsey’s involvement in the scandal – there have been internal discussions at McKinsey about destroying documents related to its work for the drug company. The settlement does not include an admission of guilt on the part of McKinsey, which, while expressing “regret” over its misjudgment of the opioid crisis, sees its own actions as siding with the law. Still, it hit the consulting firm hard, at least financially: the sum to be paid, more than half a billion, is higher than what the company earned from its opioid-manufacturing clients like Purdue according to a New York Times report (2021). The settlement is also groundbreaking in that it is the first settlement with a non-pharmaceutical company due to entanglements in the opioid crisis. It also shows that taking legal action against consulting firms that in the past claimed to “only” provide recommendations for action, but not to be involved in their implementation, is possible. So far, McKinsey had been able to avoid legal liability for scandals of its clients – one might remember, for example, the scandal surrounding the energy company Enron, which attracted a great deal of media attention.
Whether the “case” is actually closed for McKinsey with the settlement remains to be seen. Mingo County in West Virginia has already filed suit against McKinsey. More lawsuits could follow in the coming months, because the settlement does not rule out possible criminal prosecution in all U.S. states.
The legal battles are also likely to continue for Purdue: 1,000 lawsuits were pending against the company last fall. In a recent settlement with the U.S. Department of Justice, Purdue finally agreed to pay $8.3 billion to settle federal civil and criminal cases. However, the company filed for bankruptcy in the process, so it is questionable whether the government will ever receive the money, which is meant for the fight against the epidemic. It would certainly be of great importance. After all, this sum only seems high at first glance, considering that the follow-up costs of the opioid crisis for the state amount to around $500 billion annually.
At the intersection of institutionalized practices, socioeconomic structures, and the U.S. health care system
But how could it come to this? The reasons are manifold. On the one hand, deviant behavior in the organizational field of the pharmaceutical industry – and this does not mean the manufacturers exclusively, but also, among others, the cooperating partners and suppliers – is a common and institutionalized practice and a systemic problem. Legal violations and legal disputes are business as usual (see also the article on off-label marketing and medical ghost writing). Therefore, the rule violations in the context of the opioid crisis is no exception.
Nevertheless, it is not only the actions of the pharmaceutical companies involved, such as Purdue Pharma, Allergan, Johnson & Johnson or Teva Pharmaceutical Industries, which have resulted from manifest economic motivation that have helped the opioid crisis to its “breakthrough”. The U.S. health care system also plays a significant role in this, because private and public health care providers generally do not fund prolonged pain therapies such as physical therapy, but they do fund powerful drugs that promise rapid success even for complex health problems. Pills appear – at least at first glance – “cheaper”. The resulting problem mainly affects the socio-economically disadvantaged population in the poorer rural areas of the US, such as West Virginia, Delaware and Ohio. This is because many jobs in the counties hardest hit by the crisis are mostly those in mining, manufacturing or the military. These are low-paid jobs that require hard physical labor which pose high health risks (see our blog about Trump’s coal buddies). Chronic diseases are often the result, but the alternatives to opioid painkillers are not affordable (this applies to miners, for example, about whom we have already reported here). Another structural problem follows: poor access to health care away from (large) cities. Non-drug therapies are not only unaffordable, but also often non-existent.
The marketing of the pharmaceutical industry hit on the fertile ground of social-structural disadvantages. Thus, the opioid crisis cannot be chalked up in a direct inference to the pharmaceutical companies alone for it is embedded in a complex of problems that also make combating the underlying causes a difficult task. For example, according to estimates from the U.S. Department of Health and Human Services, about 10 million Americans abused opioids in 2019. In Germany, opioid painkillers are only available on narcotic prescription – probably one of the reasons why the number of addictions has remained relatively stable at 166,000 (2016) for 20 years. However, according to an OECD report, prescribing patterns are slowly changing in Germany as well, and opioid painkillers are increasingly being prescribed for chronic pain. So, is it only a matter of time before we have a situation similar to the one in the U.S.?
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