‘You want a description of hell?’
`OxyContin’s 12-hour problem
`
`by Harriet Ryan, Lisa Girion and Scott Glover
`May 5, 2016
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`OxyContin 80 pills (Liz Baylen / Los Angeles Times)
`
`The drugmaker Purdue Pharma launched OxyContin two decades ago with a
`bold marketing claim: One dose relieves pain for 12 hours, more than twice as
`long as generic medications.
`
`Patients would no longer have to wake up in the middle of the night to take
`their pills, Purdue told doctors. One OxyContin tablet in the morning and
`one before bed would provide “smooth and sustained pain control all day
`and all night.”
`
`1996
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`OxyContin Press Release
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`When Purdue unveiled OxyContin in 1996, it touted 12-hour duration.
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`OxyContin’s 12-hour problem
`
`by Harriet Ryan, Lisa Girion and Scott Glover
`May 5, 2016
`
`OxyContin 80 pills (Liz Baylen / Los Angeles Times)
`
`The drugmaker Purdue Pharma launched OxyContin two decades ago with a
`bold marketing claim: One dose relieves pain for 12 hours, more than twice as
`long as generic medications.
`
`Patients would no longer have to wake up in the middle of the night to take
`their pills, Purdue told doctors. One OxyContin tablet in the morning and
`one before bed would provide “smooth and sustained pain control all day
`and all night.”
`
`1996
`
`OxyContin Press Release
`
`When Purdue unveiled OxyContin in 1996, it touted 12-hour duration.
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`On the strength of that promise, OxyContin became America’s bestselling
`painkiller, and Purdue reaped $31 billion in revenue.
`
`But OxyContin’s stunning success masked a fundamental problem: The drug
`wears off hours early in many people, a Los Angeles Times investigation
`found. OxyContin is a chemical cousin of heroin, and when it doesn’t last,
`patients can experience excruciating symptoms of withdrawal, including an
`intense craving for the drug.
`
`The problem offers new insight into why so many people have become
`addicted to OxyContin, one of the most abused pharmaceuticals in U.S.
`history.
`The Times investigation, based on thousands of pages of
`confidential Purdue documents and other records, found that:
`Purdue has known about the problem for decades. Even before
`OxyContin went on the market, clinical trials showed many patients
`weren’t getting 12 hours of relief. Since the drug’s debut in 1996, the
`company has been confronted with additional evidence, including
`complaints from doctors, reports from its own sales reps and
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`independent research.
`The company has held fast to the claim of 12-hour relief, in part to
`protect its revenue. OxyContin’s market dominance and its high price —
`up to hundreds of dollars per bottle — hinge on its 12-hour duration.
`Without that, it offers little advantage over less expensive painkillers.
`When many doctors began prescribing OxyContin at shorter intervals
`in the late 1990s, Purdue executives mobilized hundreds of sales reps to
`“refocus” physicians on 12-hour dosing. Anything shorter “needs to be
`nipped in the bud. NOW!!” one manager wrote to her staff.
`Purdue tells doctors to prescribe stronger doses, not more frequent ones,
`when patients complain that OxyContin doesn’t last 12 hours. That
`approach creates risks of its own. Research shows that the more potent
`the dose of an opioid such as OxyContin, the greater the possibility of
`overdose and death.
`More than half of long-term OxyContin users are on doses that public
`health officials consider dangerously high, according to an analysis of
`nationwide prescription data conducted for The Times.
`
`Over the last 20 years, more than 7 million Americans have abused
`OxyContin, according to the federal government’s National Survey on Drug
`Use and Health. The drug is widely blamed for setting off the nation’s
`prescription opioid epidemic, which has claimed more than 190,000 lives
`from overdoses involving OxyContin and other painkillers since 1999.
`
`The internal Purdue documents reviewed by The Times come from court
`cases and government investigations and include many records sealed by the
`courts. They span three decades, from the conception of OxyContin in the
`mid-1980s to 2011, and include emails, memos, meeting minutes and sales
`reports, as well as sworn testimony by executives, sales reps and other
`employees.
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`The documents provide a detailed picture of the development and marketing
`of OxyContin, how Purdue executives responded to complaints that its effects
`wear off early, and their fears about the financial impact of any departure
`from 12-hour dosing.
`
`Reporters also examined Food and Drug Administration records, Patent
`Office files and medical journal articles, and interviewed experts in pain
`treatment, addiction medicine and pharmacology.
`
`Experts said that when there are gaps in the effect of a narcotic like
`OxyContin, patients can suffer body aches, nausea, anxiety and other
`symptoms of withdrawal. When the agony is relieved by the next dose, it
`creates a cycle of pain and euphoria that fosters addiction, they said.
`
`OxyContin taken at 12-hour intervals could be “the perfect recipe for
`addiction,” said Theodore J. Cicero, a neuropharmacologist at the
`Washington University School of Medicine in St. Louis and a leading
`researcher on how opioids affect the brain.
`
`Patients in whom the drug doesn’t last 12 hours can suffer both a return of
`their underlying pain and “the beginning stages of acute withdrawal,” Cicero
`said. “That becomes a very powerful motivator for people to take more
`drugs.”
`
`Video | 0:27
`
`The cycle of addiction
`
`Peter Przekop, a neuroscientist and physician who oversees the treatment of
`painkiller addicts at the Betty Ford Center in Rancho Mirage, said that
`repeated episodes of withdrawal from OxyContin “absolutely” raise the risk
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`that patients will abuse the medication.
`
`“You are messing with those areas of the brain that are involved in addiction,
`and you are going to get the person dependent on it,” he said.
`
`The Times sought comment from Purdue’s scientists and executives. At the
`company’s request, the newspaper submitted detailed questions in writing.
`Purdue responded with a one-page statement noting that the FDA approved
`OxyContin as a 12-hour drug.
`
`“Scientific evidence amassed over more than 20 years, including more than a
`dozen controlled clinical studies, supports FDA’s approval of 12-hour dosing
`for OxyContin,” Purdue’s chief medical officer, Dr. Gail Cawkwell, said.
`
`Company officials said in the same statement that “the people at Purdue have
`dedicated themselves to helping address our nation’s opioid epidemic.”
`‘I have it under control. I know what I’m doing.’
`As an LAPD officer, Ernest Gallego was fearless. He broke up bar fights and
`street brawls. During a torrential rainstorm in 1980, he waded into a flooded
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`intersection to rescue two motorists.
`
`He was on duty in Echo Park seven years later when a tow truck slammed
`into his patrol car, leaving him with a career-ending back injury. He had
`several surgeries and tried various pain medications over the next two
`decades.
`
`By 2012, he was on OxyContin. His parents and siblings watched and worried
`as the strong, fastidiously neat man they knew became wobbly on his feet
`and unkempt. His father, an attorney, wrote letters on his law office letterhead
`pleading with his son’s doctor to take him off the drug, and his mother hid
`any OxyContin bottles she found, Gallego’s sister, Kathryn Galvan, recalled.
`
`“He was having car accidents, fender benders. Very groggy all the time,” she
`said. He spent much of his day sleeping. When confronted, “He would say, ‘I
`have it under control. I know what I’m doing.’”
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`(Kathryn Galvan)
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`“I have it under control. I know what Iʼm doing.”
`
`— Kathryn Galvan recalling the words of her brother, Ernest P. Gallego
`
`Gallego died. A toxicology test showed lethal levels of oxycodone in his blood.
`
`When his mother died in 2012, Gallego showed up at the funeral disheveled
`and confused.
`
`A month and a half later, a police officer found him slumped over the
`steering wheel of his car in a convenience store parking lot and took him to
`the hospital, according to a coroner’s report and his sister. The next evening,
`he laid down on the floor of his father’s living room in La Verne, as he often
`did to relieve his pain. He never awoke. He was 58.
`
`A toxicology test showed lethal levels of oxycodone in his blood. The label on
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`an OxyContin bottle found nearby directed Gallego to take an 80 milligram
`pill every 12 hours, according to the coroner’s office. Based on the date Gallego
`filled the prescription, there should have been 44 pills left. There were 7.
`‘Remember, effective relief just takes two’
`Purdue developed OxyContin as a cure for pain — and for a financial
`problem.
`
`The company’s owners were the Sacklers, a New York family of physicians
`and philanthropists who bought Purdue in 1952. By the late 1980s, the patent
`on its main source of revenue, a morphine pill for cancer patients called MS
`Contin, was running out. Executives anticipated a massive loss of revenue as
`generic versions drove down the price of MS Contin, according to internal
`company correspondence from the period.
`
`The company was focused on finding a new moneymaker. In a 1990 memo,
`Robert F. Kaiko, vice president for clinical research, laid out why it was
`important to develop a second painkiller.
`
`“MS Contin may eventually face such serious generic competition that other
`controlled-release opioids must be considered,” Kaiko wrote.
`
`1990
`
`Purdue's Need for a New Painkiller
`
`In this 1990 memo, Robert Kaiko, the scientist who would go on to help invent
`OxyContin, explains why Purdue needs another painkiller.
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`Purdue already had developed a technique to stretch a drug’s release over
`time. In MS Contin, the technique made morphine last eight to 12 hours.
`Kaiko and his colleagues decided to use it on an old, cheap narcotic,
`oxycodone.
`
`Sold under several names and formulations, including Percocet and
`Roxicodone, oxycodone controls pain for up to six hours.
`
`With the delayed-release technique, executives theorized, the drug would last
`12 hours — at least twice as long as generics and the high end of MS Contin’s
`range.
`
`Over the next decade, Purdue sunk more than $40 million into development
`of OxyContin, Paul D. Goldenheim,then-vice president of scientific and
`medical affairs, wrote in a 2003 court declaration.
`
`Sales and marketing representatives gathered at the company’s headquarters,
`then in Norwalk, Conn., in March 1995 to start planning the roll-out of the
`new drug.
`
`“OxyContin can cure the vulnerability of the ... generic threat and that is why
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`it is so crucial that we devote our fullest efforts now to a successful launch of
`OxyContin,” then chief executive Michael Friedman told the group,
`according to minutes of the meeting.
`
`1995
`
`OxyContin Launch
`
`At a 1995 meeting, Purdue executives described how OxyContin could "cure"
`the "vulnerability" of generic competition and laid out how they planned to
`market the drug.
`
`The first patients to use OxyContin were women recuperating from
`abdominal and gynecological surgery at two hospitals in Puerto Rico in 1989.
`In the clinical study, designed and overseen by Purdue scientists and paid for
`by the company, 90 women were given a single dose of the drug while other
`patients were given short-acting painkillers or placebos. None of the women
`were regular users of painkillers, so they were more susceptible to the effects
`of narcotics.
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`Even so, more than a third of the women given OxyContin started
`complaining about pain in the first eight hours and about half required more
`medication before the 12-hour mark, according to an FDA analysis of the
`study.
`
`The study found that OxyContin was safe, relieved pain and lasted longer
`than the short-acting painkillers.
`
`Purdue moved ahead on two paths: seeking patents for its new drug and
`running additional clinical trials to secure FDA approval.
`
`In a 1992 submission to the Patent Office, the company portrayed OxyContin
`as a medical breakthrough that controlled pain for 12 hours “in
`approximately 90% of patients.” Applying for a separate patent a few years
`later, Purdue said that once a person was a regular user of OxyContin, it
`“provides pain relief in said patient for at least 12 hours after administration.”
`
`1992
`
`OxyContin Patent
`
`Applying for a patent in 1992, Purdue said OxyContin controlled pain for 12
`hours "in approximately 90% of patients."
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`Purdue’s researchers, meanwhile, were conducting at least a half dozen
`clinical trials, according to the company’s FDA application. In study after
`study, many patients given OxyContin every 12 hours would ask for more
`medication before their next scheduled dose.
`
`For example, in one study of 164 cancer patients, one third of those given
`OxyContin dropped out because they found the treatment “ineffective,”
`according to an FDA analysis of the study. Researchers then changed the
`rules of the study to allow patients to take supplemental painkillers, known
`as “rescue medication,” in between 12-hour doses of OxyContin.
`
`In another study of 87 cancer patients, “rescue was used frequently in most of
`the patients,” and 95% resorted to it at some point in the study, according to a
`journal article detailing the clinical trial.
`
`A Tennessee pain specialist whom Purdue selected to field-test the drug in
`1995 as part of the FDA approval process eventually moved 8 of 15 chronic
`pain patients to 8-hour dosing because they were not getting adequate relief
`taking the drug twice a day.
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`This prompted a letter from Purdue’s medical director.
`
`“This situation concerns me as OxyContin has been developed for q12h
`dosing,” Dr. Robert Reder wrote to the Memphis physician, using medical
`shorthand for 12-hour dosing. “I request that you not use a q8h dosing
`regimen.”
`
`Narcotic painkillers work differently in different people. Some drug
`companies discuss that variability on their product labels and recommend
`that doctors adjust the frequency with which patients take the drugs,
`depending on their individual response.
`
`The label for Purdue’s MS Contin, for instance, recommends that doctors
`prescribe the drug every eight or 12 hours to suit the patient. The morphine
`tablet, Kadian, manufactured by Actavis, is designed to be taken once a day,
`but the label states that some patients may need a dose every 12 hours.
`
`Despite the results of the clinical trials, Purdue continued developing
`OxyContin as a 12-hour drug. It did not test OxyContin at more frequent
`intervals.
`
`To obtain FDA approval, Purdue had to demonstrate that OxyContin was safe
`and as effective as other pain drugs on the market. Under agency guidelines
`for establishing duration, the company had to show that OxyContin lasted 12
`hours for at least half of patients. Purdue submitted the Puerto Rico study,
`which showed that.
`
`The FDA approved the application in 1995.
`
`Dr. Curtis Wright, who led the agency’s medical review of the drug, declined
`to comment for this article. Shortly after OxyContin’s approval, he left the
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`FDA and, within two years, was working for Purdue in new product
`development, according to his sworn testimony in a lawsuit a decade ago.
`
`The Times asked the FDA for comment on the drug’s failure to provide 12
`hours of relief for many patients. Officials at the agency declined to be
`interviewed.
`
`In a written statement, spokeswoman Sarah Peddicord said that although the
`FDA approved OxyContin for use every 12 hours, “it should be well
`understood by physicians that there will be some individual variability in the
`length of time that patients respond to this drug...
`
`“While the labeled dosing regimen is a reasonable starting point, physicians
`should carefully individualize their approach to patients based on how
`quickly they metabolize the drug,” Peddicord wrote.
`
`After OxyContin hit the market in 1996, ads in medical journals left no
`ambiguity about how long it lasted. A spotlight illuminated two dosage cups,
`one marked 8 AM and the other 8 PM.
`
`“REMEMBER, EFFECTIVE RELIEF JUST TAKES TWO,” the ads said.
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`A 1997 OxyContin advertisement in the American Family Physician shows marketing promoting the benefits
`of 12-hour dosing. (Liz. O. Baylen / Los Angeles Times)
`
`‘What time is it? Oh, God, I have to medicate'
`The year OxyContin was introduced, Elizabeth Kipp, a 42-year-old stay-at-
`home mom, went to her doctor in Kansas City, Kan. She had struggled with
`back pain since age 14, when she was thrown from a horse while practicing
`for an equestrian competition.
`
`In the intervening decades, she’d taken short-acting generic painkillers. On
`that day in 1996, her physician said he had something new for her to try.
`
`He told her to take OxyContin every 12 hours. Kipp, who had a bachelor’s
`degree in plant science from the University of Delaware, said she followed his
`instructions precisely.
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`“I’m a scientist, very regimented,” she said.
`
`For the first two or three hours, she experienced a “modicum of relief.” Then
`her pain roared back, accompanied by nausea, she said in an interview. Only
`the next pill would relieve her suffering.
`
`She spent hours lying rigidly on her bed, waiting.
`
`“I was watching the clock. ‘What time is it? Oh, God, I have to medicate,' ” she
`said. “My whole nervous system is on red alert.”
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`(Dan Ray / For The Times)
`
`“You want a description of hell? I can give it to you.”
`
`— Elizabeth Kipp
`
`Kipp began taking OxyContin in 1996 to cope with pain from a back injury sustained when she was 14.
`
`When she complained to her doctor, he gave her stronger doses but kept her
`on the 12-hour schedule, as Purdue instructs physicians to do. The change
`had little effect.
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`For a year and a half, she spent each day cycling through misery and relief.
`Sometimes, she said, she contemplated suicide.
`
`“You want a description of hell,” Kipp recalled. “I can give it to you.”
`
`She eventually checked herself into rehab and said she no longer takes
`painkillers.
`‘It’s Bonus Time in the Neighborhood!’
`Before OxyContin, doctors had viewed narcotic painkillers as dangerously
`addictive and primarily reserved their long-term use for cancer patients and
`the terminally ill. Purdue envisioned a bigger market.
`
`“We do not want to niche OxyContin just for cancer pain,” a marketing
`executive explained to employees planning the drug’s debut, according to
`minutes of the 1995 meeting.
`
`The company spent $207 million on the launch, doubling its sales force to
`600, according to a court declaration. Sales reps pitched the drug to family
`doctors and general practitioners to treat common conditions such as back
`aches and knee pain. Their hook was the convenience of twice-a-day dosing.
`
`With Percocet and other short-acting drugs, patients have to remember to
`take a pill up to six times a day, Purdue told doctors. OxyContin “spares
`patients from anxious ‘clockwatching,’” a 1996 news release said.
`
`Sales reps showered prescribers with clocks and fishing hats embossed with
`“Q12h.” The company invited doctors to dinner seminars and flew them to
`weekend junkets at resort hotels, where they were encouraged to prescribe
`OxyContin and promote it to colleagues back home.
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`A clock that Purdue distributed to doctors and healthcare
`professionals to promote OxyContin. (Liz. O. Baylen / Los Angeles
`Times)
`
`The marketing succeeded in ways that astonished even Purdue executives.
`OxyContin didn’t just replace MS Contin revenues. It dwarfed them.
`
`By the third year, sales were more than double MS Contin’s peak, according
`to sworn testimony by a Purdue executive. By the fifth, OxyContin was
`generating annual revenue of more than $1 billion. Sales would continue to
`climb until 2010, when they leveled off at $3 billion.
`
`Purdue’s owners, the Sackler family, were already rich — the family name
`adorns a wing of the Metropolitan Museum of Art and several galleries in the
`British Museum. The success of OxyContin brought a whole new level of
`wealth. Forbes magazine last year estimated the Sacklers’ worth at $14 billion,
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`which, the magazine noted, put the family ahead of American dynasties such
`as the Mellons and Rockefellers.
`
`OxyContin’s impact on the practice of medicine was similarly transformative.
`Other drug companies began marketing their own narcotic painkillers for
`routine injuries. By 2010, one out of every five doctor’s visits in the U.S. for
`pain resulted in a prescription for narcotic painkillers, according to a Johns
`Hopkins University study.
`
`OxyContin accounted for a third of all sales revenue from painkillers that
`year, according to industry data.
`
`OxyContin Sales, 1996-2014
`$3 billion
`
`012
`
`’06
`
`’08
`
`’10
`
`’12
`
`’04
`’02
`’00
`’98
`’96
`Source: IMS National Sales Perspectives
`Rates of addiction and overdose have soared alongside the rise in
`prescriptions. News coverage of these problems in Appalachia and New
`England in the late 1990s made OxyContin notorious. Purdue dispatched
`representatives to Virginia, Maine and elsewhere to defend its drug. They
`blamed misuse of OxyContin and insisted their pill was a godsend for pain
`
`’14
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`@latimesgraphics
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`sufferers when taken as directed.
`
`“A lot of these people say, ‘Well, I was taking the medicine like my doctor told
`me to,’ and then they start taking them more and more and more,” Purdue
`senior medical director, Dr. J. David Haddox, told a reporter in 2001. “I don’t
`see where that’s my problem.”
`
`The U.S. Justice Dept. launched a criminal investigation, and in 2007 the
`company and three top executives pleaded guilty to fraud for downplaying
`OxyContin’s risk of addiction. Purdue and the executives were ordered to pay
`$635 million. The case centered on elements of Purdue’s marketing campaign
`that suggested to doctors that OxyContin was less addictive than other
`painkillers.
`
`In the years after the settlement, Purdue funded programs to prevent
`pharmacy robberies and keep teenagers from stealing relatives’ pills. The
`company eventually rolled out a tamper-resistant version of the painkiller
`that was harder to crush and snort.
`
`But in all the scrutiny of Purdue and OxyContin, the problem of the drug
`wearing off early was not addressed.
`
`Purdue sales reps who spent their days visiting doctors to talk up OxyContin
`heard repeatedly that the drug didn’t last. In reports to headquarters, they
`wrote that many physicians were prescribing it for three or even four doses a
`day.
`
`Company officials worried that if OxyContin wasn’t seen as a 12-hour drug,
`insurance companies and hospitals would balk at paying hundreds of dollars
`a bottle.
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`Some already were.
`
`Dr. Lawrence Robbins started prescribing OxyContin at his Chicago migraine
`clinic shortly after it hit the market. The neurologist recalled in an interview
`that “70 to 80%” of his patients reported that the drug “just lasts four, five, six,
`seven hours.” Robbins started telling people to take it more frequently. But
`insurance carriers often refused to cover the pharmacy bill for more than two
`pills a day, he said.
`
`Over the years, he wrote insurance companies more than 25 times on behalf
`of patients who he believed needed OxyContin more frequently than every 12
`hours, he said. In some cases, the insurers relented. When others did not,
`Robbins switched the patients to another drug.
`
`Robbins said he had no choice: “If they are having a real struggle with opioid
`withdrawal, sure, you have to do something.”
`
`For Purdue, doctors like Robbins were a problem that had to be confronted.
`
`“I am concerned that some physicians are using OxyContin on a q8h
`schedule rather than a q12h schedule,” a regional manager in Atlanta,
`Windell Fisher, wrote in November 1996 — 11 months after OxyContin went
`on sale.
`
`1996
`
`Sales Manager on Q12 dosing
`
`In this 1996 letter, a Purdue regional manager writes that he is concerned
`about doctors prescribing OxyContin at 8-hour intervals. Sales reps should
`visit those physicians and convince them to go back to 12-hour dosing, he
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`writes.
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`In the memo, Fisher told a district sales manager what to do:
`
`“Where this is occurring you need to train the representative on how to deal
`with it, convincing the physician that there is no need to do this, and that
`100% of the patients in the studies had pain relief on a q12h dosing regimen.”
`
`By 2000, it was clear that chiding memos to sales reps weren’t enough. Data
`analyzed by company employees showed that one in five OxyContin
`prescriptions was for use every eight hours, or even more frequently.
`
`Purdue held closed-door meetings to retrain its sales force on the importance
`of 12-hour dosing, according to training documents, some included in sealed
`court files and others described in FDA files.
`
`“These numbers are very scary,” managers warned sales reps during one
`workshop.
`
`2004
`
`FDA Filing
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`In a 2004 petition to the FDA, attorneys for the state of Connecticut described
`the alarm inside Purdue when some doctors began prescribing OxyContin at
`more frequent intervals. "These numbers are very scary," sales reps were told.
`
`“Managed care plans are beginning to refuse to fill prescriptions,” they were
`told in another presentation. Reps were ordered to visit doctors and “refocus
`the clinician back to q12h.” Doctors needed to be reminded “on every call,”
`they were told.
`
`“There is no Q8 dosing with OxyContin,” one sales manager told her reps,
`according to a memo cited in an FDA filing. She added that 8-hour dosing
`“needs to be nipped in the bud. NOW!!”
`
`If a doctor complained that OxyContin didn’t last, Purdue reps were to
`recommend increasing the strength of the dose rather than the frequency.
`There is no ceiling on the amount of OxyContin a patient can be prescribed,
`sales reps were to remind doctors, according to the presentation and other
`training materials.
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`2001
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`Workshop Presentation
`
`After some physicians began prescribing OxyContin more frequently than
`every 12 hours, Purdue summoned its sales force to special seminars. As this
`2001 presentation shows, company officials were concerned more frequent
`dosing would hurt business.
`
`Boosting the dosage could extend the duration to some degree, but it didn’t
`guarantee 12 hours of relief. Higher doses did mean more money for Purdue
`and its sales reps. The company charged wholesalers on average about $97 for
`a bottle of the 10-milligram pills, the smallest dosage, while the maximum
`strength, 80 milligrams, ran more than $630, according to 2001 sales data the
`company disclosed in litigation with the state of West Virginia. Commissions
`and performance evaluations for the sales force were based in part on the
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`proportion of sales from high-dose pills.
`
`A West Virginia supervisor told one of his highest performing sales reps in a
`1999 letter that she could “blow the lid off” her sales and earn a trip to Hawaii
`if she persuaded more doctors to write larger doses.
`
`In an August 1996 memo headlined “$$$$$$$$$$$$$ It’s Bonus Time in the
`Neighborhood!” a manager reminded Tennessee reps that raising dosage
`strength was the key to a big payday.
`
`1996
`
`Letter to Sales Reps
`
`In this 1996 memo entitled "It's Bonus Time in the Neighborhood," a Purdue
`sales manager told her staff to talk up stronger doses of OxyContin in
`conversations with doctors.
`
`“He who sells 40mg” the largest pill available at the time “will win the
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`battle,” the manager wrote.
`
`By 2004, Purdue was seeing “a trend away from prescribing OxyContin” more
`frequently than every 12 hours, according to a company filing with the FDA.
`
`In the training materials reviewed by The Times, little was said about the
`effect of higher doses on patient health. Those on higher doses of opioids are
`more likely to overdose, according to numerous research studies. An analysis
`of the medical records of more than 32,000 patients on OxyContin and other
`painkillers in Ontario, Canada, found that one in 32 patients on high doses
`fatally overdosed.
`
`“In other words,” the lead researcher, David Juurlink, said in an interview,
`“they are more likely to die as a result of their medication than almost
`anything else.”
`‘Death was looking real good to me’
`As a varsity athlete at the University of Central Florida and later a public
`school teacher, Burgess MacNamara was used to following rules.
`
`That changed in 1999 when he had knee surgery and his doctor put him on
`OxyContin. MacNamara, then a 27-year-old gym teacher at an elementary
`school near Orlando, was familiar with painkillers. He’d been given Percocet
`and Vicodin for sports injuries, but he said OxyContin was unlike anything
`he’d ever experienced.
`
`“The first six hours, it is awesome,” he said. Then the effect began to “teeter
`off” and he became preoccupied with his next dose: “That’s all you think
`about. Your whole day revolves around that.”
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`MacNamara said he soon began taking pills early.
`
`“I can’t even tell you the times I actually waited 12 hours,” he said. “There
`weren’t many of them.”
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`(Christopher Berkey for the Los Angeles Times)
`
`“Death was looking real good to me. ”
`
`— Burgess MacNamara
`
`MacNamara began taking OxyContin in 1999, after a knee surgery.
`
`Within a month, he was crushing and snorting the pills. Within a year, he was
`forging prescriptions. He eventually tried heroin, which was cheaper, and
`other drugs. MacNamara was arrested for forging prescriptions, possession of
`controlled substances, stealing pills from a school clinic and other drug-
`fueled crimes. He lost his teaching career and spent 19 months behind bars.
`
`“Death was looking real good to me,” recalled MacNamara, who said he has
`been sober for the last two and a half years.
`‘I was more or less a zombie’
`As OxyContin’s popularity grew, a handful of scientists outside Purdue
`published research raising questions about the 12-hour claim. Scientists
`affiliated with the Oklahoma University College of Medicine found in 2002
`that nearly 87% of those prescribed OxyContin at a school pain clinic were
`taking it more frequently than every 12 hours. The reason, researchers wrote,
`was “perceived end-of-dose failure.”
`
`A separate study underwritten by a Purdue competitor, Janssen
`Pha
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