Tag Archives: opioid crisis

06/7/22

A Coming Opioid Storm?

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When Rahul Gupta was sworn in as the Director of the Office of National Drug Policy (ONDCP) on November 18, 2021, he said on Twitter that the overdose epidemic would be his top priority. He is the first physician to lead the ONDCP. President Biden made it clear to him that addressing the overdose epidemic was an urgent priority. “As director, I will diligently work to advance high-quality, data-driven strategies to make our communities healthier and safer.” Tellingly, the day before Gupta was sworn in, the CDC reported on November 17th that there were an estimated 100,306 drug overdose deaths in the U.S. during the 12-month period ending in April of 2021, an increase of 28.5% from the same time period the year before.

Overdose deaths from opioids increased to 75,673 in the year prior to April 2021, an increase of 35% from the same time period the year before. Nearly 500,000 people died from overdoses involving any opioid from 1999-2019. The CDC said this took place in three distinct waves, with commonly prescription opioids (1990s), heroin (2010) and synthetic opioids (2013). See the graph below, which shows the three categories as well as opioids overall.

The Stanford-Lancet Commission was formed in response to the rising opioid-related morbidity and mortality rates in the USA and Canada over the past 25 years. An article by Humphreys et al in The Lancet in February of 2022, “Responding to the opioid crisis in North America,” noted that in the past 25 years, more people died of overdoses in the USA and Canada than World War 1 and World War 2 combined. Following the above-noted waves, the article made the following observations.

Humphreys et al said the approval of Purdue Pharma’s opioid medication OxyContin in 1995 marked the beginning of the first wave. Purdue fraudulently marketed it as less addictive than other opioids and thus more acceptable for a broad range of indications at high doses. See “Giving an Opioid Devil Its Due,” “The Tale of the OxyContin Lie,” and “Doublespeak in the Opioid Crisis, Part 2” for more on Purdue Pharma and OxyContin.

Backed by the most aggressive marketing campaign in the history of the pharmaceutical industry, OxyContin became the best known of a number of opioid medications (both extended-release and immediate-release formulations) whose prescription rate exploded in the USA and Canada.

There was a departure from decades of medical practice where opioids were used mainly for cancer, surgery and palliative care (people living with a serious illness like cancer). US and Canadian medical practitioners expanded opioid prescribing to include a broad range of non-cancer pain conditions that included lower back pain, headaches and sprained ankles. Per-person opioid prescribing roughly quadrupled between 1999 and 2011. There were 275 million opioid prescriptions written—approximately equal to the population of the two nations. The following graph shows UN data on international per-person consumption of opioids in 2010-12.

The political and cultural environment at the time the crisis emerged was not conducive to an early response; indeed, complacency allowed it to worsen. To attain respectability, trust, and influence throughout the world, opioid manufacturers strategically donated a small share of their profits to prominent institutions, including hospitals, medical and dental schools, universities, museums, art galleries, and sporting events. These donations secured goodwill and increased the credibility of the industry’s message that it was a selfless healer, pushing back against cruel anti-opioid prejudices.

The second wave began around 2010, as drug traffickers realized individuals addicted to prescription opioids were an untapped potential market for heroin. People were drawn in by the comparatively lower price of heroin. Before controls on prescribing were introduced, an analysis of national data suggested that 79.5% of Americans using heroin started with prescription opioids. When efforts began to stop the increase in prescriptions and reduce diversion of prescription opioids, addicted people began turning to heroin more rapidly than they otherwise might have.

The third wave of the opioid crisis began around 2014, as illicit drug producers began adding extraordinarily powerful synthetic opioids, such as fentanyl, to counterfeit pharmaceutical pills, heroin, and stimulants. This wave brought unprecedented lethality in addition to—rather than instead of—the previous waves, both of which continue today. Large numbers of US and Canadian people are still becoming addicted to prescription opioids each year, and most of those who die from heroin and fentanyl overdoses are previous or current users of prescription opioids.

An anonymous editorial in The Lancet accompanied the report of the Stanford-Lancet Commission, Managing the opioid crisis in North America and beyond.” It said the COVID-19 pandemic may have contributed to the number of overdose deaths by disrupting treatment programs and access to medications like naloxone, as well as disrupting support networks. The Commission called for characterizing opioid use disorder (OUD) as a chronic condition, requiring “innovation in treatment of OUD and in the treatment of pain. However, this innovation “must be met with reinforced regulation.”

A Mental Elf article commenting on the Stanford-Lancet Report, said it was an important and authoritative summary of the development of the opioid crisis in North America. It was called an invaluable resource for anyone interested in the problems associated with opioids. But the author, Ron Poole, thought it has a number of weaknesses. He said in his opinion, “at the heart of the international opioid problem is a false belief that pain can be eliminated pharmaceutically.” If we are to move forward, we need to embrace a rehabilitation approach to chronic pain “where opioids play a small and specific role,” rather than continuing to search for an “analgesic magic bullet.”

The pain-elimination myth is not soley the creation of the pharmaceutical industry; it has deep-seated roots in medical socio-cultural beliefs.”In the UK, gabapentinoids are frequently used alongside heroin, and the combination is a potent cause of respiratory depression and death. Gabapentinoids have a limited role in pain management, but they are widely prescribed. They are dependency forming in much the same way as benzodiazepines. Gabapentinoids are not mentioned in the Report.

Poole is right to point to these weaknesses with the Stanford-Lancet Report, especially the failure to mention that gabapentin, which is the sixth-most prescribed medication in the U.S. It has an addictive potential, but is not yet a scheduled substance by the DEA. Other researchers have referred to concomitant use of gabapentinoids and heroin as an emerging public health problem. See “The Truth About Gabapentin.”

Hopefully, we will have time to implement the recommendations in the Stanford-Lancet Report. Humphreys et al said it took more than a generation of mistakes to create the opioid crisis in North America and might take a generation of wiser policies to resolve it. Let’s hope the three “waves” of the opioid crisis, illustrated in the above CDC graph, aren’t signaling a coming storm surge of the opioid epidemic before that time.

04/26/22

It’s Strictly Business

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While news on the fighting in Ukraine was dominating the headlines at the beginning of March in 2022, a struggle of a different kind came closer to an end. The legal battle between the Sackler family and Purdue Pharma on the one side, and a group of states who refused to sign off on the settlement last summer seems to have ended when both sides agreed to a mediated settlement. The New York Times reported it was the first time in three years of negotiations that all states accepted a settlement agreement with Purdue Pharma and the Sacklers. “While the deal is a breakthrough, it is likely to leave many people disappointed that members of the Sackler family did not acknowledge wrongdoing or any personal responsibility for the public health crisis.”

If the judge presiding over Purdue’s bankruptcy proceedings approves the agreement, the Sackler family would pay up to $6 billion to help communities provide assistance for the damage from the ongoing opioid crisis. This was an increase of more than $1 billion from an earlier offer. The Sacklers would have 18 years to make payments of the additional $1 billion. In return, Sackler family members would be protected from all current and future civil claims against them over their company’s prescription opioid business. However, the deal does not protect them from potential criminal cases, which are difficult to prove.

The Sacklers’ position on prohibiting future civil lawsuits was a major obstacle for states that opposed the plan. The latest deal included an agreement by the Sacklers to create a public repository of confidential documents that detail lobbying, public relations and marketing activities with OxyContin. The attorney general of Connecticut, one of the states that rejected the earlier offer, said the settlement was both significant and insufficient, “constrained by the inadequacies of our bankruptcy code.” This settlement resolves their claims against Purdue and the Sacklers, but the fight continues against the wider addiction industry.

The new mediated agreement has several additional terms. Family members from the Sackler family were to attend a hearing that would allow people who suffered from OxyContin addiction to describe what they endured. Any medical centers, art or educational institutions that bear the Sackler name can remove it without their action being contested by the family. Also, there was a statement attached to the settlement that was characterized as an “apology.” Widely described as an apology, this statement doesn’t seem to qualify as one. The Sackler family said:

The Sackler families are pleased to have reached a settlement with additional states that will allow very substantial additional resources to reach people and communities in need. The families have consistently affirmed that settlement is by far the best way to help solve a serious and complex public health crisis. While the families have acted lawfully in all respects, they sincerely regret that OxyContin, a prescription medicine that continues to help people suffering from chronic pain, unexpectedly became part of an opioid crisis that has brought grief and loss to far too many families and communities.

The new settlement still faces a difficulty. The U.S. Trustee program, which oversees the bankruptcy system within the Department of Justice, has argued vigorously against the proposed immunity shield for the Sacklers. Before the tentative agreement, there was a conflict building in the U.S. Court of Appeals for the Second Circuit. So far, the Justice Department has not commented on whether it would continue to challenge that condition of the tentative settlement.

The above-noted hearing was conducted on March 10th by the judge overseeing Purdue’s bankruptcy and featured 26 people from 19 states. The NYT said it was the first time individuals were able to directly address members of the Sackler family. The three members of the Sackler family who attended the hearing were: Dr. Richard Sackler, a former president and chairman of the board; David Sackler, a former board member; and Dame Theresa Sackler, a former board member and widow of Dr. Mortimer Sackler, one of the company’s founders.

Dame Theresa sat quietly; her expression unchanging. David Sackler sometimes shifted his position. Dr. Richard Sackler, who was the family member seen as most involved in the company’s aggressive marketing of OxyContin, remained off camera the whole session. This infuriated some of the participants. One of the individuals referred to the Sacklers as “killers,” saying that to this day, they deny any wrongdoing; that the family acted lawfully in all respects. “Richard, can you honestly say that with a straight face? If so, why don’t you turn on your camera and let’s see?”

Dr. Sackler was permitted to remain off camera by prior agreement. Also by prior arrangement, the Sacklers did not speak during the session and did not issue a statement afterwards. An individual testifying at the hearing, who was himself in recovery from an opioid addiction, quoted a statement made by Dr. Sackler in 2001, which said: “We have to hammer on the abusers in every way possible. They are the culprits and the problem. They are reckless criminals.” He then accused Richard Sackler, “You are the abuser. You are the criminal and you are the culprit . . . I hope that every single victim’s face haunts your every waking moment.”

A man from Indiana, who was a criminal court judge, lost his son to an overdose. The man and his wife began their testimony time by playing a recording of the 911 call made when they found their son dead from an overdose. He was “a straight-A student in college, studying law.” The judge said to Dr. Sackler, “I have put away drug dealers with a single rap of a gavel without blinking an eye. Oh, how I wish I could do the same to you, Richard Sackler.”

Foundations, art galleries and museums around the world have requested they become distanced from the Sackler name, including: The Metropolitan Museum of Art and the Dia Art Foundation in New York, the Serpentine Gallery and the four Tate galleries in the U.K., and the Louvre in Paris. Others, including the Guggenheim and the American Museum of Natural History in New York, and the British Museum in London have not announced plans to remove the Sackler name from their institutions.

Members of the Sackler family have persistently denied that the billions of dollars removed from Purdue Pharma over the course of a decade was done to shield assets from potential litigation over their role in the opioid crisis. But a review of emails, memos and other documents showed that Sackler family members discussed exposure to potential litigation as early as 2007, “a full decade before they faced a new wide-ranging legal attack and significant financial transfers stopped.”

Blomberg Businessweek published an article noting “How the Sacklers Shifted $10.8 Billion of Their Opioid Fortune.” Initially, Purdue and its subsidiaries moved billions to companies registered in Luxembourg, the British Virgin Islands and Delaware. “From 2008 through 2017, $10.8 billion flowed out of Purdue in hundreds of transactions through numerous subsidiaries.” The money eventually landed in two Delaware companies, Rosebay Medical Co. and Beason Co., which are trusts for the benefit of the Sackler family. See the Bloomberg article for particulars of the monetary shell game with Purdue funds.

Blomberg said a spokesperson for the family said in a statement: “All of the Sackler family members, including those who served on Purdue’s board, have always conducted themselves properly.” From 2007 to 2019, 10 Sacklers were Purdue directors. The following graphic appeared in the Blomberg article.

NPR reported last year that “Purdue Pharma conducted Massive Probe of the Sacklers, But The Findings Are Secret.” The company acknowledged hiring attorneys, forensic accountants and other financial experts to probe members of the Sackler family. The team searched for evidence of wrongdoing by the family and reported their findings to a special committee of Purdue’s board between April 2019 and March of 2021. But Purdue chose to reveal essentially nothing of what investigators uncovered. “Purdue’s disclosure filing says it paid its lawyers for a 22,000-hour investigation of the Sacklers, but it doesn’t disclose any of their findings.”

Writing for NPR, Brain Mann said the Purdue Pharma document suggests the primary goal of the investigation “was to inform and shape bankruptcy talks” that were underway at the time. Speaking on behalf of the Sacklers, spokespersons downplayed the significance of the investigation and maintained members of the family did nothing wrong. An attorney for the Raymond Sackler family said: “As we have said before, we support the release of documents and they will continue to show Sackler family members who served on Purdue’s board acted ethically and legally.”

A few clues about what investigators found were evident in the filing. The filing stated that “certain dealings between Purdue Pharma and the Sackler families and various Sackler entities were not conducted on arm’s-length terms.” There is a link to the “Alix Report on Distributions to Sacklers,” noting compensation, pension benefits, travel and expense reimbursements, legal expenses incurred on behalf of Sackler family members, and fringe benefits provided to members of the Sackler family such as cell phones, fleet vehicles and personal service employees up until April 30, 2019.

It seems the Sacklers were playing the long game from the time of Purdue’s first admission of illegal actions in “misbranding” OxyContin in 2007. See “Giving an Opioid Devil Its Due.” From 2008 until 2017 there was a transfer of over $10 billion out of the company. From 2007 to 2019, 10 different members of the Sackler family served on Purdue board. An extensive investigation by Purdue was done of members of the Sackler family looking for evidence of wrongdoing.

The investigative team reported to a special committee of the board between April of 2019 and March of 2021, but failed to publicly disclose any of its findings. The Sacklers consistently denied any wrong doing and repeatedly warned that a failure to protect family members from all current and future civil claims against them over their company’s prescription opioid business would scuttle the bankruptcy negotiations and perhaps end “The ability of creditors, communities, and individuals to receive billions in value to abate the opioid crisis,” according to Steve Miller, Purdue’s chairman.

The Sacklers will not face any civil charges; criminal filings are very difficult to prove and will likely not be filed. Despite the transfer of billions of dollars from Purdue, ultimately to family trusts, members of the family deny having done anything ethically or legally wrong. Their so-called apology was formed in non-apologetic rhetoric that took no responsibility for Purdue Pharma’s or the family’s role in birthing the opioid crisis. There is no apparent remorse by members of the Sackler family involved in the day-to-day operations and decisions of Purdue Pharma that led to the eventual addiction and deaths of hundreds, if not thousands of people. There seems to have been one unverbalized, but clearly communicated statement by the Sacklers in their so-called apology quoted above: “It’s not personal; it’s strictly business.”

For further information on the Sacklers and Purdue Pharma, see: “It Doesn’t Seem Right,” “Carrot-and-Stick Tactics of Purdue and the Sacklers” and “What Purdue and the Sackler Family Treasure.”

06/8/18

Doublespeak in the Opioid Crisis, Part 2

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Last year The New York Times reported drug overdoses were now the leading cause of death for Americans under the age of fifty. The nationwide total for drug-related deaths was around 64,000 in 2016. According to Vox, this is more than the number of soldiers killed during the entire Vietnam War (an estimated 55,000); more than the 43,000 Americans who died in car crashes at the peak of auto-related deaths in 1972; and more than the 43,000 who died of HIV/AIDS in 1995 at the height of that epidemic. A CDC infographic using data from the National Survey on Drug Use and Health (NSDUH) for 2011-2013 reported that individuals who are addicted to opioid painkillers are forty times more likely to be addicted to heroin. Let this last statistic sink in: Today’s heroin addict often begins as someone who first used opioids for pain relief.

In Part 1 of “Doublespeak in the Opioid Crisis” we saw how the misuse of a 1980 letter published in the New England Medical Journal helped to generate these statistics. Here we will look closer at how the accelerated rate in opioid prescribing and one of the players in that increase contributed to the current opioid crisis. Purdue Pharmaceuticals will be shown to have played a crucial role in the birth and growth of the opioid problem in the U.S.

In the Annual Review of Public Health, Kolodny et al. gave the following information in: “The Prescription Opioid and Heroin Crisis.” Since 2000, the consumption of hydrocodone more than doubled and the consumption of oxycodone increased by almost 500%. Parallel to this, the OPR-related overdose death rate increased almost fourfold. Between 1997 and 2011, emergency rooms saw a 900% increase of individuals seeking treatment for addiction to OPRs (opioid pain relievers). “The correlation between opioid sales, OPR-related overdose deaths, and treatment seeking for opioid addiction is striking.” See chart below taken from “The Prescription Opioid and Heroin Crisis.”

In 1986 a paper by Portenov and Foley, “Chronic Use of Opioid Analgesics in Non-Malignant Pain,” concluded that pain patients could be treated safely on a long-term basis with OPRs. “Despite its low-quality evidence, the paper was widely cited to support expanded use of opioids for chronic non-cancer pain.” Along with the misquoting and misuse of Hershel Jick’s 1980 letter in the NEMJ, the stage was being set for the coming increase in the prescription and consumption of opioids. The gradual upward trend of opioid use that began in the 1980s accelerated rapidly after the introduction of OxyContin to the OPR market in 1995.

Between 1996 and 2002, Purdue Pharma funded more than 20,000 pain-related educational programs through direct sponsorship or financial grants and launched a multifaceted campaign to encourage long-term use of OPRs for chronic non-cancer pain. As part of this campaign, Purdue provided financial support to the American Pain Society, the American Academy of Pain Medicine, the Federation of State Medical Boards, the Joint Commission, pain patient groups, and other organizations. In turn, these groups all advocated for more aggressive identification and treatment of pain, especially use of OPRs.

In 1995 the American Pain Society introduced a campaign entitled: “Pain is the Fifth Vital Sign.” Health care professionals were encouraged to assess pain with the same zeal as they do with other “vital signs”; and become more willing to use opioids to treat non-cancer pain. Before the introduction of OxyContin, physicians were reluctant to prescribe OPRs on a long-term basis for common chronic pain conditions, as they were concerned with their patients developing tolerance, physiological dependence and addiction. Opioid manufacturers, including Purdue, had physician-spokespersons publish papers and give lectures on ‘opiophobia,’ claiming the medical community has been confusing addiction and ‘physical dependence,’ which they said was “clinically unimportant.”

In “The Promotion and Marketing of OxyContin,” Art Van Zee said from 1996 to 2001 Purdue conducted more than 40 national pain management and speaker-training conferences at resorts in Florida, Arizona and California. “More than 5,000 physicians, pharmacists, and nurses attended these all-expenses-paid symposia, where they were recruited and trained for Purdue’s national speaker bureau.” In 2001 alone Purdue spent $200 million in a variety of approaches to market and promote OxyContin. Using data on the prescribing patterns of physicians nationwide, Purdue targeted physicians who were the highest prescribers of opioids across the country.

They specifically went after primary care physicians, encouraging a more liberal use of opioids. By 2003, almost half the physicians prescribing OxyContin were primary care physicians. Some experts became concerned that primary care doctors were not sufficiently trained in pain management or addiction issues. Those who worked within a managed care environment of time constraints had the least amount of time to evaluate and follow up on patients with complicated chronic pain.

There was a bonus system in place to encourage sales representatives to increase the sales of OxyContin in their territories. Physicians with high rates of opioid prescriptions received a large number of visits. In 2001, Purdue paid out almost $240 million in sales incentive bonuses to its sales representatives. From 1996 to 2000 Purdue increased its sales force from 318 to 671 sales representatives. The company also had a starter coupon program that provided patients with a 7- to 30-day supply of OxyContin. “By 2001, when the program was ended, approximately 34,000 coupons had been redeemed nationally.”

Branded promotional items like OxyContin fishing hats and stuffed plush toys were distributed. There was even a compact music disc: “Get in the Swing With OxyContin.” The breadth and scope of such marketing was unprecedented for a Schedule II opioid.

Purdue “aggressively” promoted the use of opioids for use in the “non-malignant pain market.” A much larger market than that for cancer-related pain, the non–cancer-related pain market constituted 86% of the total opioid market in 1999.  Purdue’s promotion of OxyContin for the treatment of non–cancer-related pain contributed to a nearly tenfold increase in OxyContin prescriptions for this type of pain, from about 670,000 in 1997 to about 6.2 million in 2002, whereas prescriptions for cancer-related pain increased about fourfold during that same period.

Kolodny et al. indicated that in addition to minimizing the risks of OPRs, opioid manufacturers and pain organizations exaggerated the benefits of long-term OPR use. “In fact, high-quality, long-term clinical trials demonstrating the safety and efficacy of OPRs for chronic non-cancer pain have never been conducted.” Surveys of patients with chronic non-cancer pain receiving long-term OPR treatment suggested that most patients continued to experience significant chronic pain and dysfunction. “The CDC and some professional societies now warn clinicians to avoid prescribing OPRs for common chronic conditions.”

Although increased opioid consumption over the past two decades has been driven largely by greater ambulatory use for chronic non-cancer pain, opioid use for acute pain among hospitalized patients has also increased sharply. A recent study found that physicians prescribed opioids in more than 50% of 1.14 million nonsurgical hospital admissions from 2009 to 2010, often in high doses. The Joint Commission’s adoption of the Pain is the Fifth Vital Sign campaign and federally mandated patient satisfaction surveys asking patients to rate how often hospital staff did “everything they could to help you with your pain” are noteworthy, given the association with increased hospital use of OPRs.

Van Zee indicated in “The Promotion and Marketing of OxyContin” that a consistent feature in Purdue’s promotion and marketing of OxyContin was a systematic effort to minimize the risk of addiction when using opioids to treat chronic non-cancer-related pain. In the literature and audiotapes of their promotional campaign for physicians, and on its “Partners Against Pain” website, Purdue claimed the risk of addiction from OxyContin was extremely small. Purdue trained its sales force to affirm that the risk of addiction was “less than one percent.” They cited the 1980 NEMJ letter to the editor by Jick (see Part 1 of this article for more information on this) and other studies to minimize the risk of addition. “Misrepresenting the risk of addiction proved costly for Purdue,” to the tune of $634 million in fines:

On May 10, 2007, Purdue Frederick Company Inc, an affiliate of Purdue Pharma, along with 3 company executives, pled guilty to criminal charges of misbranding OxyContin by claiming that it was less addictive and less subject to abuse and diversion than other opioids.

While research showed OxyContin was simply comparable to other available opioids in safety and efficacy, Purdue’s marketing made it into a blockbuster product. Sales escalated from $44 million in 1996 to almost $3 billion over 2001 and 2002. Prescriptions increased from 316,000 to over 14 million.

The remarkable commercial success of OxyContin, however, was stained by increasing rates of abuse and addiction. Drug abusers learned how to simply crush the controlled-release tablet and swallow, inhale, or inject the high-potency opioid for an intense morphine-like high. There had been some precedence for the diversion and abuse of controlled-release opioid preparations. Purdue’s own MS Contin had been abused in the late 1980s in a fashion similar to how OxyContin was later to be; by 1990, MS Contin had become the most abused prescription opioid in one major metropolitan area. Purdue’s own testing in 1995 had demonstrated that 68% of the oxycodone could be extracted from an OxyContin tablet when crushed.

Purdue Pharmaceuticals and its subsidiary companies are privately owned by the Sackler family, named in 2016 by Fortune Magazine as the 19th richest family in the US. None of the Sackler family has even been charged in the past litigation against Purdue. Although family members are not involved in the day-to-day operations of Purdue Pharma companies today, several Sacklers are current board members of Purdue Pharma. In “Meet the Sacklers,” Joann Walters pointed out how the Sackler family has a reputation for its cultural and academic philanthropy to institutions such as Harvard, Yale, MIT, Columbia, Cornell, Stanford and other universities in the US; as well as the Guggenheim Museum, the Smithsonian, the Serpentine Sackler Gallery, the Royal Academy in Britain and others.

Allen Frances said in his article for The Guardian there is no Pablo Escobar Wing at New York’s Metropolitan Museum of Art (there is a Sackler Wing); and no El Chapo Guzman gallery at the Guggenheim (there is a Sackler Center for Art Education). Oxford would no longer be Oxford if it had one of its libraries named in honor of the Cali cartel (but there is a Sackler Library). “The Sackler name is emblazoned on, and disgraces, dozens of the world’s greatest museums, universities, and performing arts centers. So far, none has turned down their donations, none has returned their money already given.” He thought a solution was for institutions to elicit and receive permission from the family members to remove their name, “without any quid pro quo requirement for returned funding.”

I’m not sure about that idea, but I could definitely support two other ones he suggested. First, the family should use its fortune to provide “free treatment for the people they addicted.” Second, they should mount “a reverse marketing campaign to undo their previous brainwashing of doctors and patients.” But I don’t think those ideas will ever happen.

While Purdue announced it halved its sales force and will no longer send out field representatives to promote OxyContin to health professionals in the U.S., there is no indication that the same approach will be taken by its overseas subsidiaries, such as Mundipharma. In “OxyContin Goes Global,” the LA Times noted where a network of international companies owned by the Sackler family are expanding into Latin America, the Middle East, Africa and other regions. “In this global drive, the companies known as Mundipharma, are using some of the same controversial marketing practices that made OxyContin a pharmaceutical blockbuster in the U.S.”

If you’re interested in more information on Purdue Pharma, the Sacklers and OxyContin, also look at: “The Tale of the OxyContin Lie” and “Greed With OxyContin Is NOT Good.”