Dreamland (22 page)

“They’ll work hard for a salary and they won’t cheat you,” the Nayarit said. “They’re happy for the work.”

Over a lifetime of heroin use, the Man had never heard of anyone working drugs for a salary. But he saw the ingenuity in the system. Up to that point, heroin had always been sold by dealers from some apartment or house. Eventually, cops would raid the house, so dealers were constantly moving, and having to let their customers know their new addresses. But with pagers, dealers could operate from cars, the Nayarit told him. Buyers didn’t have to expose themselves by going to an address, or a skid row, to buy their heroin. They need only keep a telephone number handy and the heroin could be brought to them. With consistent supply from Nayarit, the system offered addicts reliability, convenience, and safety.

In Reno, not long after that, the new partners started their first heroin store. They worked out the kinks, selling mostly to veteran dope fiends. It didn’t earn much—about a thousand dollars a day. But soon more guys from the village were clamoring for work; some started their own crews, saturating the market. To make money selling heroin by the tenth of a gram, you needed volume. The only way to do that was to expand to other markets.

With their Reno store still operating with the kids from Xalisco, the Nayarit and the Man moved on to Salt Lake, found a motel, and discovered that Salt Lake City had a load of old dope fiends. Still, it was a clean town. The Man had to hand it to the Mormons: They did run a clean town. Plus Salt Lake had a lot of Mexicans, so they could blend in.

Soon they were selling out. The Man sent for more dope from Reno. The Nayarit called down to Xalisco and two kids arrived in Salt Lake ready to work. They set up a cell that he claims continues to this day, run by the Nayarit’s brother-in-law.

From Salt Lake City, with two tienditas in place, they took a vacation. They flew to Mexico with thirty thousand dollars and, with his partner as a guide, the Man arrived for the first time in the town of Xalisco in the small state of Nayarit.

Swing with OxyContin

Southern Ohio

In 1997, in the town of Chillicothe, in southern Ohio, Phillip Prior, a family physician at a local hospital, began to notice salesmen from a company called Purdue Pharma making regular appearances.

The salesmen would arrive every few months to provide docs an elaborate lunch of steak, salad, and dessert. They had slides and graphics that presented the startling idea that the company’s new drug, OxyContin, was virtually nonaddictive. Less than 1 percent of patients ever grew addicted, they said in their presentations.

This claim startled Prior because OxyContin contained large doses of the opiate called oxycodone. Prior had attended medical school in the early 1980s, where he had learned opiates were generally to be avoided. He’d remembered a study that concluded that daily usage of 30 mg of oxycodone was enough to cause withdrawal.

The Purdue sales campaign contradicted “what we had learned in medical school. I was trained that they were dangerous, addictive [drugs] and only effective for a short period of time,” Prior said. “We were very hesitant to use narcotics because they’re dangerous. It flew so much in the face of what we were trained—about narcotics being a last-ditch effort for dying cancer patients, and not to be used for nonmalignant pain.”

But the salesmen had charts and graphs supporting the idea that because OxyContin was a timed-release medication that patients felt fewer of the strong highs and deep lows that led to addiction. Thus, the salesmen insisted, it could be prescribed to people with chronic pain in their backs, knees, or other joints, chronic pelvic pain, or fibromyalgia, or to women after giving birth.

“It was a very effective presentation,” Prior said. “It really did make you doubt your feelings about what you’d been taught in medical school.”

They came through often—six times in 1997 to his hospital alone, Prior remembered, and held hundreds of meetings in the southern Ohio area, all with the same message. The OxyContin sales campaign mounted by Purdue Pharma was legend, and manifest in it was the spirit of Arthur Sackler and his focus on direct contact with physicians.

Purdue had its salespeople dig in on doctors who its data showed were already heavy opiate prescribers. To expand the numbers of prescribers, sales reps also visited nurses, pharmacists, hospices, hospitals, and nursing homes. The physician call list used by Purdue sales reps began at thirty-three thousand, then rose to more than seventy thousand doctors nationwide. Purdue’s sales force tripled to more than a thousand as OxyContin gained momentum.

During these years, the company was hardly alone in this. The decade of the 1990s was the era of the blockbuster drug, the billion-dollar pill, and a pharmaceutical sales force arms race was part of the excess of the time. The industry’s business model was based on creating a pill—for cholesterol, depression, pain, or impotence—and then promoting it with growing numbers of salespeople. During the 1990s and into the next decade, Arthur Sackler’s vision of pharmaceutical promotion reached its most exquisite expression as drug companies hired ever-larger sales teams. In 1995, 35,000 Americans were pharmaceutical sales reps. Ten years later, a record 110,000 people—Sackler’s progeny all—were traveling the country selling legal drugs in America.

They crowded into doctors’ offices and hospital corridors. Pfizer, that tiny chemical concern that had hired Sackler a half century before, was now the world’s largest drug company, with blockbuster drugs like Viagra, the antidepressant Zoloft, and the best-selling drug ever, Lipitor, an anticholesterol drug. Pfizer was at the forefront of putting Sackler’s ideas into practice. Its sales force grew to thirty-eight thousand people worldwide—twelve thousand in the United States alone. Doctors complained they were getting visits by three Pfizer reps a day. The industry called it “feet on the street,” with mobs of salesmen calling on doctors to get them to change how they prescribed. But Pfizer was only the leader in an industry obsessed with blockbuster drugs and convinced that more salespeople was the way to get doctors’ attention in a crowded market. A pharmaceutical Wild West emerged. Salespeople stampeded into offices. They made claims that helped sell the drugs to besieged doctors. Those claims also led years later to blockbuster lawsuits and criminal cases against their companies.

Purdue increased the sales quota of OxyContin needed to make bonuses. Even so, salespeople surpassed every goal. In 1996, Purdue paid one million dollars in bonuses tied to Oxy sales, and forty million dollars in bonuses five years later. Some Purdue reps—particularly in southern Ohio, eastern Kentucky, and other areas first afflicted with rampant Oxy addiction—were reported to have made as much as a hundred thousand dollars in bonuses in one quarter during these years. Those were unlike any bonuses ever paid in the U.S. pharmaceutical industry. Veteran drug salespeople say that in most drug companies, a bonus for a stellar
year
is thirty thousand dollars; companies can predict how well its drugs can sell, and raise goals on drugs doing well to avoid paying such whopping bonuses. So Purdue was apparently underestimating the amount these folks could sell every year, and/or the drug, combined with the pain revolution and the idea that it was essentially nonaddictive, was virtually selling itself. Whatever the case, the bonuses to Purdue salespeople in these regions had little relation to those paid at most U.S. drug companies. They bore instead a striking similarity to the kinds of profits made in the drug underworld.

It was a good time to be a Purdue salesman.

In 2002, the Pharmaceutical Research and Manufacturers of America, a pharmaceutical trade group, and the U.S. Department of Health and Human Services put out voluntary guidelines on marketing opiate painkillers. Attempting to restrain the massive pharma sales force, they admonished companies from offering inappropriate travel, meals, and gifts to get doctors to prescribe certain drugs, and from paying excessive consulting and research fees to doctors. The guidelines prohibited giving away merchandise not related to health care.

But that was in 2002. For Oxy’s first six years, Purdue was not limited by much.

Purdue offered OxyContin coupons to physicians, who could in turn give them to patients for a onetime free prescription at a participating pharmacy. By the time Purdue discontinued the program, thirty-four thousand coupons had been redeemed.

Doctors received OxyContin fishing hats, stuffed toys, coffee mugs, golf balls, and pens with a chart converting a patient’s dose in other pills to OxyContin.
Swing Is Alive
, a CD the company gave out, urged listeners to “Swing in the Right Direction with OxyContin” and featured ten big-band tunes, including Count Basie’s “One O’Clock Jump” and “Boogie Woogie Bugle Boy” by the Andrews Sisters. Pads of message paper with the OxyContin logo were given to doctors so they would be “reminded of OxyContin every time they get a phone message.”

Many of these methods—premiums, trips, giveaways—were time-tested strategies that grew from the revolution Arthur Sackler began and were refined over time by many pharmaceutical companies. Only this time, the pill being marketed contained a large whack of a drug virtually identical to heroin. The DEA later said that no company had ever used this kind of branded merchandise to market a so-called Schedule II drug (Schedule II is a federal designation for drugs with accepted medical uses, but a high potential for abuse resulting in dependency).

Purdue held some forty pain-management and speaker-training seminars. The company recruited physicians for its national speakers bureau to talk about the use of oxycodone—and by implication OxyContin—to doctors and nurses at medical conferences and hospitals. These conferences took place in Boca Raton, Florida, and Scottsdale, Arizona, and some five thousand physicians, pharmacists, and nurses attended in the five years the seminars were offered.

Purdue also made continuing medical education (CME) an important part of its campaign. By the 1990s, CME had been around for a decade but had grown largely dependent on drug company funding. The companies shelled out hundreds of millions of dollars, usually from their marketing budgets, to fly medical practitioners to resorts. There, the companies plied them with dinners, golf outings, and spa treatments while sending them to seminars on a medical issue, led by specialists that the companies often suggested. Often the conclusion was that a drug the companies made was a solution to a medical problem. Hardworking doctors, furthermore, weren’t eager to go to unappealing places; but they flocked to resorts like Scottsdale for their CME, expecting to be catered to by wealthy drug companies.

Significant education, of course, usually did take place. Most medical professionals wouldn’t have sat through the simple hawking of drugs. But the conflicts of interest were palpable. During those years, “CME was often a clandestine marketing tool for drug companies,” said one seminar organizer who remains in the business. “Golf, dinner, wine and dine doctors and you will win these guys’ hearts and minds, or at least some of them.”

In 2004, the Accreditation Council for Continuing Medical Education wrote new rules aimed to “brighten the line” between pharmaceutical companies and the seminars. The rules now prohibit pharma company influence on content and speaker selection, as well as limitations on how grant funding can be used. Drug company funding for the seminars has since dropped off and several of the major medical education companies left the business. Now a lot of CME is online, where the risk of improper influence through resorts, dinners, and golf outings is removed.

But prior to that, Purdue sponsored CME seminars, particularly on new techniques for pain treatment, which often urged the use of unnamed timed-release opiates; not coincidentally, OxyContin was the only such pill on the market. The U.S. General Accounting Office reported that the company helped fund more than 20,000 education programs. These often included ways for physicians to get CME credits at state and local medical conferences.

Russell Portenoy was a frequent Purdue speaker and an eloquent one. He stressed the complexity of pain treatment; pain sometimes required a multidisciplinary approach, he said. But he also insisted that chronic pain was frequently best treated with long-acting opiate painkillers.

“It wasn’t like Portenoy came up with these concepts to benefit Purdue. He sincerely believed that these were miracle drugs for chronic pain,” said the CME seminar organizer, who worked with the doctor and the company. “But had Portenoy not had Purdue’s money behind him, he would have published some papers, made some speeches, and his influence would have been minor. With Purdue’s millions behind him, his message, which dovetailed with their marketing plans, was hugely magnified. He was a godsend for Purdue. All you need is one guy to say what he was saying. The others guys who are sounding a warning about these drugs don’t get funded. They get a journal article, not a megaphone.”

Video was another medium Purdue used to apparently great effect. In 1998, Purdue sent out fifteen thousand copies of a video about OxyContin to doctors around the country without submitting it to the FDA for review, contrary to the agency’s regulations.
I Got My Life Back: Patients in Pain Tell Their Story
told of the pain relief enjoyed by several patients.

Two years later, Purdue sent out another twelve thousand copies of an updated version of
I Got My Life Back
, showing patients talking about how OxyContin changed their lives. It included information on the 160 mg version of the pill, and made “unsubstantiated claims regarding OxyContin’s effect on patients’ quality of life . . . and minimized the risks associated with the drug,” according to the GAO’s 2003 report on the company’s OxyContin promo campaign.