The Science of Addiction Behind N.H.'s Lawsuit Against Big Pharma

Aug 11, 2017

The New Hampshire Attorney General's office filed a lawsuit this week against Purdue Pharma, maker of the popular opioid OxyContin. According to the Attorney General, Purdue peddled its drugs to prescribers using deceptive marketing techniques that understated the risks of addiction and overstated the drug’s benefits.

The A.G.’s Office completed an investigation into Purdue’s marketing and is now challenging the science behind it. During the investigation, the A.G. consulted with Dr. Gilbert Fanciullo, a retired pain specialist at Dartmouth-Hitchcock, who spoke with NHPR’s Peter Biello.

Do these drugs, when used appropriately, improve the quality of life for people with chronic pain as Purdue claims?

If you look at the current data, there's two things to consider. One is, do they relieve pain, just like you asked. And the second is, what's the risk associated with their use. And so in answer to the first question, I would say that in general there's no evidence to support the fact that these drugs relieve pain long term.

I would only say that, from a 30 year career in medicine, I do have some patients that benefit from the long term use of these drugs. But as a general rule, they do not. And then if you balance that against the risk—the Center for Disease Control published an article about a year ago where they described the risks associated with the use of opioids. Anybody that's on 50 milligrams of morphine per day has twice the risk of dying compared to a person who does not take that 50 milligrams of morphine a day.

And we really don't know why people die. We don't know if they're overdosing or if some of these drugs such as methadone for example can cause arrhythmia, we really don't know why the risk of death is that much higher.

Sales reps from Purdue were allegedly quite persistent in calling doctors in New Hampshire to persuade them to prescribe OxyContin, ccording to the A.G.’s office. When you were practicing at Dartmouth-Hitchcock and you received those sales calls, what was that encounter like?

So first of all, between 5 and 10 years ago, Dartmouth decided that that these encounters biased physicians prescribing habits and their care of patients in an unscientific way, and banned the drug reps from coming into Dartmouth to speak to physicians.

Prior to that, what those encounters would be like, a person would come in who is a very charismatic person and would pull out articles from his or her briefcase and say, look we have these articles that show that OxyContin is very effective for the treatment of chronic pain and completely safe—no risk at all, no risk of addiction. And here are the articles to prove it.

And they might give you something else, they might give you a clock that says OxyContin on it or a pen that says Oxycontin on it, or they might invite you to speak at one of their conferences for money. And they would take you out to dinner.

Purdue allegedly told some prescribers that patients who appeared to be abusing OxyContin rather than just seeking it for legitimate medical needs were not suffering from addiction but something called “pseudo-addiction.” Is there any medical basis for that term “pseudo-addiction”?

I think that there probably is. Not to the extent that it was pushed 10 years ago. So what that means is, let's say you break your arm and you go to the doctor. The doctor says, you can have one of these Percocet tablets twice a day, but the Percocet tablets only last four hours. They don't last 12 hours. You have a broken arm. So you're given a drug that relieves the pain but only last four hours. And so you'll overuse that drug.

That's what we typically call pseudo addiction. There were sort of axioms that went around 10 years ago when Purdue was really pushing these drugs. One was that—what's the right amount of opioid that you prescribe to somebody? There is no right amount. There is no ceiling on the dose.

That was a terrible problem. The other problem was that we didn't recommend urine toxicology testing. So this patient with the pseudo addiction, a guy that has chronic low back pain and you prescribe Percocet, five milligrams twice a day and he comes into your office 10 days later and has used up a whole month's worth of drugs in 10 days and claims that he did that because his back hurts.

Now you checked a urine toxicology specimen on him and let's say his urine then is negative for oxycodone, there's no oxycodone. That means he either took the oxycodone in the first couple of days or he's selling his oxycodone. It goes back to the fact that patient self-report is unreliable when using drugs that that can cause the disease addiction.