What is the association between a free dinner and deaths from overdose?
Photo: Einar Nilsen
In 1996, Purdue Pharma, one of the leading pharmaceutical companies in the United States, launched a new form of oxycodone – OxyContin. The drug released opioid more slowly than other analgesics and should therefore be less addictive, the company claimed (1).
‘Opioids’ is a collective term for morphine-like pharmaceutical drugs or narcotics that act on the opioid receptors in the brain (2). They all have a sedative, analgesic effect and may produce a euphoric high. Despite highly inadequate documentation, the US Food and Drug Administration (FDA) permitted twice the dose of oxycodone to be used in OxyContin as in equivalent drugs, and its low potential for abuse to be stated on the packaging. More than 20 years later, the United States has been described as ‘the Opioid Nation’ and is facing a public health problem of huge proportions (1). More than 130 people die from opioid overdoses daily, and in 2017, around 1.7 million US citizens had substance-related and addictive disorders linked to prescription opioids (3).
The majority of deaths from opioid overdose are attributable to intake of fentanyl, heroin and cocaine (4). However, prescription opioids are also frequently involved, and at the start of the opioid crisis, drugs such as OxyContin were the most common cause of such deaths. For OxyContin, like other opioids, is addictive. Many patients who started to use the drug found that they needed to take increasingly higher doses to obtain the same analgesic effect. Some discovered that the tablets could be crushed and snorted or injected to provide a strong euphoric high. OxyContin quickly became ‘the hottest thing on the street’ and more popular on the illegal market than opioids with a shorter half-life. This was completely at variance with what Purdue Pharma had advertised – and continued to claim long after the first reports emerged of deaths from overdose (5).
Purdue Pharma, owned by the hugely wealthy Sackler family, conducted an exceptionally aggressive marketing campaign for OxyContin aimed at American doctors. More and more doctors began to prescribe the drug to their patients, and at the same time the number of fatal opioid-related overdoses began to rise. JAMA Network Open recently published a study that investigated whether there is an association between marketing, prescribing and overdoses of opioid drugs (4). The results are sobering: In the states in which pharmaceutical sales representatives for opioid analgesics had most frequent contact with doctors, and doctors had received the most benefits in the form of meals, coverage of travel costs, fees and so on, the number of deaths from overdose was highest one year later.
Since the late 1990s there has been a dramatic increase in mortality among the middle-aged, non-Hispanic, white working class in the United States. These so-called ‘deaths of despair’, primarily due to overdoses, alcohol-related illnesses and suicide, have been linked to difficult economic and social conditions (6). Against this backdrop a picture emerges of a pharmaceutical industry that has cynically exploited the opportunities presented by a market that has partly been created by social changes. In one of the last of a long series of lawsuits brought against Purdue Pharma, it was recently revealed that the company has hired the consulting firm McKinsey to ascertain how they could ‘turbocharge’ the sales of OxyContin, counter efforts to reduce opioid use, and ‘counter the emotional messages from mothers with teenagers that overdosed’ (7).
In Norway, a total of 564 000 adults collected at least one prescription for opioids in 2017 (8). This corresponds to an increase in use of a little more than 9 % since 2005. The increase for oxycodone has been especially large, with almost a six-fold increase in the number of users. Although the number of deaths from narcotic drugs in 2017 was the lowest in ten years, intake of morphine, codeine and methadone were more frequent causes of death than heroin use (9). Some of the increase in the consumption of strong opioids can be attributed to an ageing population that more often requires pain management. There is nevertheless reason to be wary of a trend that follows the American pattern. Fortunately, prescribing of opioids is strictly regulated and controlled by the health authorities. However, the primary responsibility for correct use of opioids lies with individual doctors. Moreover, we should think long and hard before we accept an invitation to a sponsored dinner.
