I am writing an article on a very similar topic, but arrive at some different conclusions. As far as I can tell, the problem with OxyContin was not the high dosage, although journalists have attempted that argument. The forerunner of OxyContin, MS Contin, had much higher dosages, yet it has maintained a clean record throughout the opioid crisis. In addition, Purdue Pharma discontinued the headiest form of OxyContin in attempts to counter abuse and diversion. The company also invested heavily in other efforts to combat the opioid crisis, which of course documentaries like Dopesick leave out.
Did Purdue make tragic mistakes? No question. Were they driven by profit? Of course. But the opioid crisis was not in their corporate interest, and there is much more to the story.
It's conceivable to me that semantics may have some role in why Oxycontin led to a drug epidemic, and MS-Contin did not.
General practitioner physicians--and dentists--had long been familiar with prescribing oxycodone for moderate pain, in the form of Percodan (oxycodone with aspirin) and Percocet (oxycodone plus acetaminophen.) That's long been the most commonly prescribed opioid pill, at least as far back as the 1960s.
By contrast, the MS Contin formulation uses morphine. GPs and dentists are notably averse to prescribing morphine. I suspect that's related to the semantic situation I noted: "Morphine" sounds more like Hard Drugs. Whereas the had active ingredient in Oxycontin was the same opioid that GPs had been prescribing for decades.
In actuality, the equianalgesic tables agree that oxycodone is at least 50% more powerful than morphine by weight.
Purdue had "regulatory exclusivity" over MS Contin- time-release morphine- that expired in May 29, 1990. Purdue first submitted a patent application for Oxycontin in 1995. It was approved by the FDA in 1996. Oxycontin was given a heavy sales push as a brand-new product. That's how Oxycontin became so overwhelmingly popular as a prescription opioid, while MS Contin was relegated to comparative obscurity.
"In the early 1990s, MS Contin, a controlled-release form of morphine sulfate, was generating millions of dollars in sales for Purdue Pharma.32 But MS Contin no longer had IP-protected exclusivity,33 and Purdue expected generic competition to eat into its profits.34 The firm pivoted to a new pain treatment market strategy..." https://pmc.ncbi.nlm.nih.gov/articles/PMC8248977/
"Purdue Pharma discontinued the headiest form of OxyContin in attempts to counter abuse and diversion."
According to the FDA, Oxycontin is still available in strengths up to 80mg. The only strength that's been discontinued is the 160mg tablet. That was never a commonly prescribed (or diverted) dose. I don't have access to detailed records on that history (although I'd venture they can be found in the documents entered into discovery in the many court trials against Purdue and other defendants that ended with culpability verdicts.) I've been reading forums by recreational opioid users for over a decade, and the dosages that I most often find mentioned are 80mg and 40mg. Those strengths are still available. Although nowadays much more stringently controlled, a history that I've outlined in my opioid-related Substack posts.
"The company also invested heavily in other efforts to combat the opioid crisis, which of course documentaries like Dopesick leave out."
As I noted in the post, although I haven't watched the docudrama Dopesick, I have read the book, by Beth Macy. I've also read Dreamland, by Sam Quinones, and Pain Killer, by Barry Meier. Along with a lot of other reports and news articles. This is a good overview of Purdue's role in aggressively promoting Oxycontin, with a detailed outline of the sort of evidence that has led to the multi-billion collar civil verdicts against Purdue. https://pmc.ncbi.nlm.nih.gov/articles/PMC2622774/
I'll be interested in reading your post, to learn what you might be able to add to that story.
Thanks for this detailed response, DC. (Thank you especially for the link to the old version of the Orange Book. Those can be hard to find!) I think you're absolutely right about the differences between the active ingredients, both in their public perceptions and the biochemistry.
When he was deposed, Richard Sackler mentioned that morphine had the reputation of being an "end of life" drug, and many prescribers mistook oxycodone as being much weaker (perhaps because oxycodone often was part of combination pills, which needed to have lower dosage to avoid nasty side effects like liver toxicity). In internal documents, Michael Friedman repeatedly cautioned against altering that perception of oxycodone, since it worked to the company's advantage.
Interestingly, even though OxyContin sold well, and even though it was often maligned by government officials and the press, the Washington Post found that OxyContin never amounted to more than 4% of the total national sales for opioids. This seems to be one reason why Pro Publica, among other outlets, have instead emphasized morphine milligram equivalent, which increases the perceived contribution of Purdue Pharma to the opioid crisis to something like 16%.
I do apologize if my prior comment suggested that your information was coming from the Dopesick documentary. That wasn't my intent, and clearly you know a lot. I just have a habit of critiquing the documentary.
Out of curiosity, are you familiar with the Opioid Industry Document Archive (OIDA)? I think you allude to it in your reference to documents obtained through legal discovery. But in case you haven't, it has so much great stuff: https://www.industrydocuments.ucsf.edu/opioids/
Since we both write about opioids, I'm sure we'll have some great back and forth on this app. I need to check out your prior posts on opioids, which sound really cool. I may disagree at points, and my reading comprehension on the internet isn't always the best, but I assure you that I'm friendly. I love discussing things that matter, such as the war on drugs and the opioid crisis, and am always open to changing my mind.
you probably know more about this history than me: for the longest time, there was no prescription accountability across state lines, and it was easy to doctor-shop, and the regulations and accountability were different with every state, and each pharmacy regulation board was different as far as inventory control, and...it was just a mess. Nowadays 48 of 50 states are connected to a central Federal database, but iirc back around 2014 fewer than 20 had signed on. One of those Federalism things, each state makes up their own regulations. There was also a Washington Post series about some of the conflicts with lobbying organizations, etc. https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/
Some substances need to be controlled, I think. Without loopholes that sluice pills out the side window by the million, and without overcompensating in ways that leave people with serious chronic pain in misery.
This is good. Looking forward to communicating more. Especially since some of what I'm going to be bringing up is more about laying out various policy alternatives and their possible consequences as thoroughly as I can without oversimplifying or strawmanning or concern-trolling or hand-waving, because I just not all that sure of myself on some of these questions. Sloganeering rhetoric is easy. Crafting realistic drug policy that isn't iatrogenic is difficult. But I've been around enough to have some strong views, based on how I've seen things actually play out in real time on the ground over the past 55 years or so. Over and beyond my reading on the subject, which is extensive.
There are a lot of people here who are worth listening to. Three of them, off the bat: Ioan Grillo, Ben Westhoff, Kevin Dahlgren. My major was cultural anthropology, but all three of them have done more fieldwork and gotten deeper into the realm of old-school thick description ethnography than I have. I consider myself more of a historian, doing historiography.
Hell, in its day, cocaine revolutionized dentistry and eye surgery. It was the first local anesthetic.
In fact, newer anesthetics, Novocain, Harvacain, etc. are basically synthetic cocaine, designed to amplify pain-killing properties and not the euphoria.
One of the main issues with Oxy, up til 2010ish, was the nature of the time release mechanism, by simply washing the pills with a little water one was able to crush up the pills and get the entire time release dose in one sitting(disclaimer, I abused opiates for years and had many experiences using oxy back in the day). You could wash an 80 milligram pill, crush and snort it to get a very heroin like high. Starting around 2009 Purdue changed the formulation and putting water on the pills turned them into a waxy mess, this completely changed the nature of oxy and took away it's biggest selling point, a truly euphoric high was replaced by an hour of being stoned, an hour of feeling like shit, an hour of being stoned, etc. After this it's time as the #1 choice for pill heads came to an end, at least for me.
I've always found the timing of this change odd, 2009-10 was the height of the US involvement in Afghanistan, troops were protecting the opium crops there, all of a sudden there media stories every where about the horrors of prescription opiates which leads to a crackdown on doctors, pill addicts find it much harder to get scripts so they start to buy heroin, seems like the whole situation was planned in advance. After reading Alfred McCoy's book The Politics of Heroin I tend to think it was planned in advance, way too much money to be made off the misery of others.
I reject the notion that there was any coordination between Purdue's reformulation of prescription pills in 2010--and the increasing pressure for prescription accountability and quantity restrictions in 2014--and the surge in Afghanistan that led to an increase in the US heroin supply. The renewed emphasis on Afghanistan under Obama was no secret; it was a campaign promise. Yes, Karzai was dirty, Karzai's brother even dirtier, and so were the Taliban, etc. The Afghan opium crop had been replanted by 2003, and the harvest had been booming for several years by 2009. Most Afghan heroin went to supply demand in Eastern Hemisphere markets. Some of it undoubtedly went to the US- but the increasing domination of the US distribution and retail markets by Mexican cartels in the 2000s meant that they favored supplies from their own "source country."
2014 was also around the time that the Mexican syndicates discovered the online markets and the Dark Web, and their in-house opium>morphine>heroin supply chain was largely replaced by the fentanyls. The fentanyls were not only absurd bargains compared to the overhead expenses of growing poppies and refining them into heroin, for a while some of them were not even prohibited substances. Up until 2018, various fentanyl analogs could be ordered legally from China and sent directly to US customers, and most likely Mexican customers as well. At first, the Mexican syndicates didn't even have to mix their own from precursors. They just bought it by the kilo. (Could American junkies have stocked up with a lifetime supply for a few hundred dollars, all nice and legal-like? Yes. For those who weren't sleeping on the opportunity, so to speak.)
Prior to 2018, fentanyl analogs were only "emergency scheduled" by the DEA as they were identified- which meant that innovative chemists could simply move a side chain, come up with a different but similarly active substance, and escape legal penalty for possession. Finally in 2018 a bill was passed that only required that the substance in question be part of the same chemical family to qualify as Schedule I prohibited https://www.samhsa.gov/sites/default/files/meeting/documents/fentanyl-analogs-06112019.pdf
I remember being mystified by learning that the original time release was so easy to defeat, just by chewing the pills! As if Purdue had no idea that anyone would dream of doing that, or snorting the powder. Obviously, gel technology was available.
I'm curious if you have any experience with the counterfeit fentanyl pills. Or what you might have heard from someone you've known.
Thankfully I do not have an experience with the fentanyl pills, quit using in late 2018 and never came across any. IMO, the fake pills are directly tied to the Opium wars, China is exacting revenge for the century of humiliation they suffered due to the West forcing opium down their throats. This would explain the nature of the fake pills, no dealer wants to kill their customers, is extremely bad for business, so why would they knowingly sell, let's say Adderall, they know to be fake and is actually fentanyl? Why sell one of the most potent opiates to people who are not looking for it unless it's a policy instituted at the state level of a geopolitical rival? All the dealers I ever knew were just looking for a quick buck, they weren't actively trying to kill people with their products but with all these fake pills around now it seems like dealers are actively trying to kill their customer base.
I am writing an article on a very similar topic, but arrive at some different conclusions. As far as I can tell, the problem with OxyContin was not the high dosage, although journalists have attempted that argument. The forerunner of OxyContin, MS Contin, had much higher dosages, yet it has maintained a clean record throughout the opioid crisis. In addition, Purdue Pharma discontinued the headiest form of OxyContin in attempts to counter abuse and diversion. The company also invested heavily in other efforts to combat the opioid crisis, which of course documentaries like Dopesick leave out.
Did Purdue make tragic mistakes? No question. Were they driven by profit? Of course. But the opioid crisis was not in their corporate interest, and there is much more to the story.
Stay tuned...
It's conceivable to me that semantics may have some role in why Oxycontin led to a drug epidemic, and MS-Contin did not.
General practitioner physicians--and dentists--had long been familiar with prescribing oxycodone for moderate pain, in the form of Percodan (oxycodone with aspirin) and Percocet (oxycodone plus acetaminophen.) That's long been the most commonly prescribed opioid pill, at least as far back as the 1960s.
By contrast, the MS Contin formulation uses morphine. GPs and dentists are notably averse to prescribing morphine. I suspect that's related to the semantic situation I noted: "Morphine" sounds more like Hard Drugs. Whereas the had active ingredient in Oxycontin was the same opioid that GPs had been prescribing for decades.
In actuality, the equianalgesic tables agree that oxycodone is at least 50% more powerful than morphine by weight.
Purdue had "regulatory exclusivity" over MS Contin- time-release morphine- that expired in May 29, 1990. Purdue first submitted a patent application for Oxycontin in 1995. It was approved by the FDA in 1996. Oxycontin was given a heavy sales push as a brand-new product. That's how Oxycontin became so overwhelmingly popular as a prescription opioid, while MS Contin was relegated to comparative obscurity.
"In the early 1990s, MS Contin, a controlled-release form of morphine sulfate, was generating millions of dollars in sales for Purdue Pharma.32 But MS Contin no longer had IP-protected exclusivity,33 and Purdue expected generic competition to eat into its profits.34 The firm pivoted to a new pain treatment market strategy..." https://pmc.ncbi.nlm.nih.gov/articles/PMC8248977/
https://pmc.ncbi.nlm.nih.gov/articles/PMC8248977/#fn33 "Although numerous articles describe Purdue as having a patent on MS Contin that was set to expire around 1995, no such patent is listed in the FDA Orange Book in the 1980s or 1990s; rather, Purdue had regulatory exclusivity that expired in 1990. See US Food & Drug Admin., Approved Drug Products with Therapeutic Equivalence Evaluations AD27 (10th ed. 1990) (listing MS Contin as having new dosage form exclusivity that would expire on May 29, 1990, and no listed patents), http://data.nber.org/fda/orange-book/historical/1986-2016/1_orange_book_PDFs/full_books_1980-2016/1990.pdf."
"Purdue Pharma discontinued the headiest form of OxyContin in attempts to counter abuse and diversion."
According to the FDA, Oxycontin is still available in strengths up to 80mg. The only strength that's been discontinued is the 160mg tablet. That was never a commonly prescribed (or diverted) dose. I don't have access to detailed records on that history (although I'd venture they can be found in the documents entered into discovery in the many court trials against Purdue and other defendants that ended with culpability verdicts.) I've been reading forums by recreational opioid users for over a decade, and the dosages that I most often find mentioned are 80mg and 40mg. Those strengths are still available. Although nowadays much more stringently controlled, a history that I've outlined in my opioid-related Substack posts.
"The company also invested heavily in other efforts to combat the opioid crisis, which of course documentaries like Dopesick leave out."
As I noted in the post, although I haven't watched the docudrama Dopesick, I have read the book, by Beth Macy. I've also read Dreamland, by Sam Quinones, and Pain Killer, by Barry Meier. Along with a lot of other reports and news articles. This is a good overview of Purdue's role in aggressively promoting Oxycontin, with a detailed outline of the sort of evidence that has led to the multi-billion collar civil verdicts against Purdue. https://pmc.ncbi.nlm.nih.gov/articles/PMC2622774/
I'll be interested in reading your post, to learn what you might be able to add to that story.
Thanks for this detailed response, DC. (Thank you especially for the link to the old version of the Orange Book. Those can be hard to find!) I think you're absolutely right about the differences between the active ingredients, both in their public perceptions and the biochemistry.
When he was deposed, Richard Sackler mentioned that morphine had the reputation of being an "end of life" drug, and many prescribers mistook oxycodone as being much weaker (perhaps because oxycodone often was part of combination pills, which needed to have lower dosage to avoid nasty side effects like liver toxicity). In internal documents, Michael Friedman repeatedly cautioned against altering that perception of oxycodone, since it worked to the company's advantage.
Interestingly, even though OxyContin sold well, and even though it was often maligned by government officials and the press, the Washington Post found that OxyContin never amounted to more than 4% of the total national sales for opioids. This seems to be one reason why Pro Publica, among other outlets, have instead emphasized morphine milligram equivalent, which increases the perceived contribution of Purdue Pharma to the opioid crisis to something like 16%.
I do apologize if my prior comment suggested that your information was coming from the Dopesick documentary. That wasn't my intent, and clearly you know a lot. I just have a habit of critiquing the documentary.
Out of curiosity, are you familiar with the Opioid Industry Document Archive (OIDA)? I think you allude to it in your reference to documents obtained through legal discovery. But in case you haven't, it has so much great stuff: https://www.industrydocuments.ucsf.edu/opioids/
Since we both write about opioids, I'm sure we'll have some great back and forth on this app. I need to check out your prior posts on opioids, which sound really cool. I may disagree at points, and my reading comprehension on the internet isn't always the best, but I assure you that I'm friendly. I love discussing things that matter, such as the war on drugs and the opioid crisis, and am always open to changing my mind.
you probably know more about this history than me: for the longest time, there was no prescription accountability across state lines, and it was easy to doctor-shop, and the regulations and accountability were different with every state, and each pharmacy regulation board was different as far as inventory control, and...it was just a mess. Nowadays 48 of 50 states are connected to a central Federal database, but iirc back around 2014 fewer than 20 had signed on. One of those Federalism things, each state makes up their own regulations. There was also a Washington Post series about some of the conflicts with lobbying organizations, etc. https://www.washingtonpost.com/graphics/2017/investigations/dea-drug-industry-congress/
https://www.washingtonpost.com/graphics/2019/investigations/drug-industry-plan-to-defeat-dea/
Some substances need to be controlled, I think. Without loopholes that sluice pills out the side window by the million, and without overcompensating in ways that leave people with serious chronic pain in misery.
This is good. Looking forward to communicating more. Especially since some of what I'm going to be bringing up is more about laying out various policy alternatives and their possible consequences as thoroughly as I can without oversimplifying or strawmanning or concern-trolling or hand-waving, because I just not all that sure of myself on some of these questions. Sloganeering rhetoric is easy. Crafting realistic drug policy that isn't iatrogenic is difficult. But I've been around enough to have some strong views, based on how I've seen things actually play out in real time on the ground over the past 55 years or so. Over and beyond my reading on the subject, which is extensive.
There are a lot of people here who are worth listening to. Three of them, off the bat: Ioan Grillo, Ben Westhoff, Kevin Dahlgren. My major was cultural anthropology, but all three of them have done more fieldwork and gotten deeper into the realm of old-school thick description ethnography than I have. I consider myself more of a historian, doing historiography.
Hell, in its day, cocaine revolutionized dentistry and eye surgery. It was the first local anesthetic.
In fact, newer anesthetics, Novocain, Harvacain, etc. are basically synthetic cocaine, designed to amplify pain-killing properties and not the euphoria.
One of the main issues with Oxy, up til 2010ish, was the nature of the time release mechanism, by simply washing the pills with a little water one was able to crush up the pills and get the entire time release dose in one sitting(disclaimer, I abused opiates for years and had many experiences using oxy back in the day). You could wash an 80 milligram pill, crush and snort it to get a very heroin like high. Starting around 2009 Purdue changed the formulation and putting water on the pills turned them into a waxy mess, this completely changed the nature of oxy and took away it's biggest selling point, a truly euphoric high was replaced by an hour of being stoned, an hour of feeling like shit, an hour of being stoned, etc. After this it's time as the #1 choice for pill heads came to an end, at least for me.
I've always found the timing of this change odd, 2009-10 was the height of the US involvement in Afghanistan, troops were protecting the opium crops there, all of a sudden there media stories every where about the horrors of prescription opiates which leads to a crackdown on doctors, pill addicts find it much harder to get scripts so they start to buy heroin, seems like the whole situation was planned in advance. After reading Alfred McCoy's book The Politics of Heroin I tend to think it was planned in advance, way too much money to be made off the misery of others.
I reject the notion that there was any coordination between Purdue's reformulation of prescription pills in 2010--and the increasing pressure for prescription accountability and quantity restrictions in 2014--and the surge in Afghanistan that led to an increase in the US heroin supply. The renewed emphasis on Afghanistan under Obama was no secret; it was a campaign promise. Yes, Karzai was dirty, Karzai's brother even dirtier, and so were the Taliban, etc. The Afghan opium crop had been replanted by 2003, and the harvest had been booming for several years by 2009. Most Afghan heroin went to supply demand in Eastern Hemisphere markets. Some of it undoubtedly went to the US- but the increasing domination of the US distribution and retail markets by Mexican cartels in the 2000s meant that they favored supplies from their own "source country."
2014 was also around the time that the Mexican syndicates discovered the online markets and the Dark Web, and their in-house opium>morphine>heroin supply chain was largely replaced by the fentanyls. The fentanyls were not only absurd bargains compared to the overhead expenses of growing poppies and refining them into heroin, for a while some of them were not even prohibited substances. Up until 2018, various fentanyl analogs could be ordered legally from China and sent directly to US customers, and most likely Mexican customers as well. At first, the Mexican syndicates didn't even have to mix their own from precursors. They just bought it by the kilo. (Could American junkies have stocked up with a lifetime supply for a few hundred dollars, all nice and legal-like? Yes. For those who weren't sleeping on the opportunity, so to speak.)
Prior to 2018, fentanyl analogs were only "emergency scheduled" by the DEA as they were identified- which meant that innovative chemists could simply move a side chain, come up with a different but similarly active substance, and escape legal penalty for possession. Finally in 2018 a bill was passed that only required that the substance in question be part of the same chemical family to qualify as Schedule I prohibited https://www.samhsa.gov/sites/default/files/meeting/documents/fentanyl-analogs-06112019.pdf
I remember being mystified by learning that the original time release was so easy to defeat, just by chewing the pills! As if Purdue had no idea that anyone would dream of doing that, or snorting the powder. Obviously, gel technology was available.
I'm curious if you have any experience with the counterfeit fentanyl pills. Or what you might have heard from someone you've known.
Thankfully I do not have an experience with the fentanyl pills, quit using in late 2018 and never came across any. IMO, the fake pills are directly tied to the Opium wars, China is exacting revenge for the century of humiliation they suffered due to the West forcing opium down their throats. This would explain the nature of the fake pills, no dealer wants to kill their customers, is extremely bad for business, so why would they knowingly sell, let's say Adderall, they know to be fake and is actually fentanyl? Why sell one of the most potent opiates to people who are not looking for it unless it's a policy instituted at the state level of a geopolitical rival? All the dealers I ever knew were just looking for a quick buck, they weren't actively trying to kill people with their products but with all these fake pills around now it seems like dealers are actively trying to kill their customer base.