Documenting Pharma’s Role in the Opioid Crisis
Opioid industry documents illuminate the cynical strategies that led to thousands of deaths. Can an archive turn the tragic past into a better future?
“GOOOOOOOOOOOD MORNING TEAM EXTREME!”
It’s 3:37 a.m. on Wednesday, March 23, 2011, and a district manager just sent his pharmaceutical sales team an email to pump them up.
He reminds them to capture the doctor’s attention “in the first 3/5ths of a second.” He implores them to develop “sneezers” (physician office employees who spread product information). He calls on them to share their best pain medication stories. He tells them to leverage the “Golden Rule” to increase sales.
Then he urges them to emulate Napoleon’s Imperial Guard, the emperor’s elite soldiers. “You need to be the best trained, educated and prepared soldier that enters the doctors’ offices each day,” he writes.
He closes with: “GOOD SELLING!”
The email gives just a glimpse into pharmaceutical companies’ sales tactics revealed in Opioid Industry Documents Archive, a searchable online collection of 1.5 million documents collected after litigation. Earlier this year, Johns Hopkins and the University of California San Francisco added 1.4 million documents to the archive from Mallinckrodt, a leading manufacturer of opioid painkillers now in bankruptcy. The archive also includes more than 114,000 documents from McKinsey & Company, which consulted on opioid sales and marketing.
From company emails to internal presentations and reports, the vast trove of records provides an extraordinary tool for people looking to understand the country’s opioid crisis. Between 1999 and 2020, more than half a million people died from prescription and illicit opioid overdoses. This collection from the past has the potential to shape the country’s future, observers say.
“People may think it’s just paper, old words,” says Charlotte Bismuth, JD, an author and former Manhattan assistant district attorney who successfully prosecuted a landmark opioid case against a physician accused of running a “pill mill.” “But it’s telling us everything we need to know about how for-profit pharmaceuticals [companies] operate and what they did.”
From company emails to internal presentations and reports, the vast trove of records provides an extraordinary tool for people looking to understand the country’s opioid crisis.
The archives also may hold the answers to important questions about the U.S. regulatory system, says Jeremy Greene, MD, PhD, MA, a History of Medicine professor at Johns Hopkins and part of the archive team. For example, does the country’s legal structure allow too much flexibility for marketing at the expense of public health? Do we need to tighten regulations for marketing dangerous products and create ways to make more enforcement possible?
These are the kind of questions “the archives can shine a light on, but it requires detailed research,” he says. “It’s going to be really exciting watching what new insights come out of this.”
There’s reason for high expectations for the archive. A similar effort called the Truth Tobacco Industry Documents created a window into Big Tobacco’s tactics that included concealing information about nicotine’s addictive properties and research on the harm caused by smoking and secondhand exposure. Some of the internal documents led to tightened industry regulations and shaped prevention education. The opioid archive team is looking for similar impacts.
“The documents provide an information repository that isn’t typically available for public health research,” says Caleb Alexander, MD, MS, an internist, Epidemiology professor, and plaintiff’s expert in opioid litigation leading the Hopkins effort. “Many important discoveries are yet to be made.”
Diving Into the Documents
From attorneys to activists, individuals are already exploring the vast repository, bringing their distinct life experiences and interests to their searches.
Bismuth, the former prosecutor, is drawn to the tool that filters search results for Mallinckrodt email communications. When she finds a troublesome thread, she’ll cross reference the author’s name with professional networking sites to see where they work now. An “uncomfortable number” have been promoted within the pharmaceutical industry, she says.
“One of the unexploited riches of the archives is so many names of people who really built their careers in this industry,” she says. “What industries are they influencing now?”
Johns Hopkins School of Medicine postdoctoral fellow Jason Chernesky, PhD, wants to know if and how certain racial or ethnic groups may have been targeted. Those searches led him to intriguing documents about the industry’s drug-diversion monitoring programs and the surveillance of local pharmacies. He’s now researching how the role of race-based health disparities factored in marketing strategies among opioid manufacturers.
Advocate and author Ryan Hampton says he’s interested in using the archives to see how pharmaceutical companies used shadow or front groups to influence various players—including activists like himself. He’s always viewed interactions with unknown groups through the lens of: “Is this group real?” Now, he can type in those names and see what emerges.
Understanding dishonest marketing strategies is also a goal of Pennsylvania parent Cynthia Munger, whose son experienced an opioid addiction. From a home office piled high with industry litigation documents, Munger has searched the online archives for evidence of how companies misrepresented addiction information. She shared some of those findings in a focus group discussion with University of Pennsylvania medical school students last spring, part of an effort to personalize the face of opioid use disorder and reduce stigma.
Exposing the ‘Playbook’
At Hopkins, associate professor Cecília Tomori, PhD, an anthropologist and director of Global Public Health and Community of Health at the School of Nursing with a joint appointment in the Bloomberg School’s Department of Population, Family and Reproductive Health, is using these unearthed materials to educate future health care professionals. The archives hold many concrete examples of the industry’s “playbook,” which includes intimidating and vilifying critics, undermining legitimate science, and influencing the political process.
“If you look at the documents in the archives, you can map out pieces of the playbook,” she says. “Well-meaning people fall prey to this.”
Tomori’s presentations link to archived texts that reveal how the playbook works. For example, she shows students a Purdue Pharma document that proposes positioning that company as part of the solution in the fight against prescription drug abuse and diversion. From the most recent McKinsey documents, she includes an image describing how sales reps can “target physicians by type,” from early adopters to resigned followers and delayers.
The benefits of revealing these approaches extend beyond the pharmaceutical industry.
New Jersey resident Ed Bisch, who lost his 18-year-old son Eddie to an overdose two decades ago, got a closer look at some of these strategies while reading American Cartel, a book about the opioid industry. When the authors referenced the “crisis playbook,” Bisch took out his phone and pulled up the opioid archive. He quickly found a 45-page industry guide to crisis communication strategies which describes how to handle everything from Congressional inquiries to counterfeit drugs in the supply chain. Publicly exposing these approaches offers Bisch some hope that they will be recognized more clearly in the future.
“For years and years, there was secrecy,” Bisch says. “I watched the epidemic play out in slow motion over the years, and I couldn’t understand why no one was doing anything concrete to stop it.”
The benefits of revealing these approaches extend beyond the pharmaceutical industry, Tomori says.
Marketing experts recycle the same strategies and tools over and over in different fields. Integrating content like this into the core health care curricula would help future health providers recognize and respond to cynical marketing efforts in all health arenas, from tobacco to infant formula.
What’s Next?
The UCSF/Hopkins archives team continues to process more than 5 million additional documents, which will eventually be added to the collection. The current documents still hold countless untold stories, they say.
That means plenty of material for journalists interested in digging, too, says The New York Times’ Chris Hamby, MA, who reported an investigative piece based on the McKinsey documents.
Hamby and his team decided to focus on McKinsey’s work with Endo Pharmaceuticals because there wasn’t a lot known about that relationship. Readers emailed to say they valued the spotlight on companies other than Purdue that contributed to the opioid epidemic, he says. He also heard from medical professionals who appreciated the insider knowledge of how companies may target them.
“People will be drawing on this material for years and years to come for more insights.” —Chris Hamby, The New York Times
Other journalists might use the archive to uncover local impacts of opioid marketing or to uncover the subtle ways in which physicians are nudged to prescribe certain products.
“People will be drawing on this material for years and years to come for more insights,” Hamby says.
As part of his postdoc at Hopkins, Chernesky hopes to use the archives to engage communities devasted by the epidemic. One possibility is to interview the most affected people and use their voices to enhance the meaning of the records. Oral histories could counteract the dehumanizing and stigmatizing way people are addressed in these industry documents, he says.
As for Bisch, the New Jersey parent, he hopes the archives help reveal the structures, strategies, and players behind the country’s opioid crisis—and the countless losses. Understanding that the crisis didn’t happen by accident may help avert future catastrophes, he says. Much like the Tobacco documents, transparency can lead to change.
“Unless there is real accountability, this is going to happen again,” he says.