The Opioid Crisis: How Purdue Pharma Started an Epidemic

Purdue Pharma created the opioid crisis through deliberate, documented marketing fraud. In 1996, Purdue introduced OxyContin to the U.S. market, claiming its time-release formulation made it safer and less addictive than other opioids. That claim was false, and Purdue’s marketing team knew it.^1^ Over the next twenty years, OxyContin became the most commercially successful prescription drug in the history of American medicine and the ignition point for an opioid crisis that by 2021 was killing more than 80,000 Americans annually — a casualty count that now exceeds annual U.S. traffic fatalities.

Part of Meth and the Opioid Crisis — ← Back to series hub

The Two Lies at the Center of OxyContin’s Launch

Oxycodone is a semi-synthetic opioid derived from thebaine, an alkaloid extracted from opium. It produces pain relief by binding to opioid receptors in the brain and spinal cord and carries a well-understood risk of addiction and dependence shared by all opioids. There was nothing pharmacologically novel about OxyContin. What was novel was its marketing.

Purdue’s central marketing claim was that OxyContin’s time-release formulation produced a “smooth” blood level curve that reduced the peaks associated with euphoria — and therefore addiction — relative to immediate-release oxycodone. The FDA approved this characterization, and Purdue used it aggressively.

There were two problems. First, the time-release formulation could be defeated by crushing the tablet, which released the full dose immediately. Purdue knew by the late 1990s that OxyContin was being crushed and snorted or dissolved and injected by people who had developed addictions.^2^ Second, even taken as directed, OxyContin was producing addiction at significant rates. The claim that extended-release formulation meaningfully reduced addiction risk relative to other opioids was not supported by the clinical evidence available to Purdue, and the evidence accumulated rapidly in the years after the drug’s launch.

How Purdue’s Sales Force Targeted the Right Doctors

Purdue Pharma’s marketing operation for OxyContin was organized and aggressive. The company deployed a large sales force — at its peak, approximately 1,000 representatives — tasked with visiting physicians and convincing them to prescribe OxyContin for conditions well beyond its initially approved use for moderate-to-severe chronic pain. Sales representatives provided physicians with free samples, sponsored continuing medical education programs that promoted opioid prescribing, and presented data on OxyContin’s safety that was incomplete and misleading.

The company targeted high-volume opioid prescribers, identified through prescription monitoring data purchased from health information companies — a practice that was legal at the time. The prescribers who wrote the most opioid prescriptions were those who received the most attention from Purdue representatives. These included many physicians in rural Appalachia, a region with high rates of occupational injury and chronic pain — and with limited access to non-opioid pain management options — that would go on to have some of the highest rates of opioid addiction and overdose in the country.^3^

Purdue’s sales force grew OxyContin revenues from approximately $48 million in 1996 to $1.1 billion in 2000. By 2010, OxyContin had generated more than $3 billion annually for several consecutive years.

Who the Sackler Family Was and What They Knew

Purdue Pharma was owned by the Sackler family, a wealthy New York family that had built its fortune through pharmaceutical holdings and had become prominent philanthropists with their names on galleries, museums, and university buildings on multiple continents. Arthur Sackler, who died in 1987, had pioneered pharmaceutical advertising in the 1950s and 1960s, building the model of direct physician marketing that Purdue would apply to OxyContin. His brothers Mortimer and Raymond continued the company.

The Sacklers were closely involved in OxyContin’s development and marketing strategy. Richard Sackler, a son of Raymond who rose to the company’s presidency, was a driving force behind the OxyContin launch and its aggressive marketing posture. Internal Purdue documents released through litigation in later years showed that Sackler family members received detailed briefings on addiction concerns and complaints about misleading marketing and continued to push growth targets.^1^

Beth Macy’s 2018 book Dopesick and the subsequent Hulu series documented the family’s involvement and the community-level consequences of OxyContin in Appalachian Virginia and West Virginia with granular, named detail.

Why Appalachia Was Hit First and Hardest

The opioid crisis followed OxyContin’s distribution network, which meant it followed Purdue’s marketing geography. The communities hardest hit in the epidemic’s first phase — the late 1990s through mid-2000s — were disproportionately rural, white, and working-class, particularly in Appalachia: southwestern Virginia, West Virginia, eastern Kentucky, and southern Ohio. These were communities with high rates of occupational injury, decades of economic decline following the collapse of coal and manufacturing employment, and limited medical infrastructure.

In Mingo County, West Virginia — one of the counties most severely affected — the overdose death rate reached 97 per 100,000 by 2016, more than five times the national average at the time. The Charleston Gazette-Mail won a Pulitzer Prize in 2017 for its reporting documenting that drug companies and distributors had shipped 780 million hydrocodone and oxycodone pills to West Virginia between 2007 and 2012 — enough to supply every resident of the state with 433 pills — without the monitoring systems that should have triggered scrutiny.^2^

How the Prescription Epidemic Became a Heroin and Fentanyl Crisis

The opioid crisis did not remain contained to prescription drugs. As OxyContin and other prescription opioids became more difficult to obtain — through prescription monitoring programs, prescription limits, and eventual reformulation of OxyContin in 2010 to be more difficult to abuse — people who had developed opioid dependence turned to the street market. Heroin, which was cheaper and widely available, became the next stage for many people whose opioid dependency had started with a prescription.

Between 2010 and 2015, heroin overdose deaths increased approximately 300 percent. Then fentanyl entered the supply chain. Illicit fentanyl — primarily produced in Chinese and later Mexican chemical facilities — began appearing in the heroin supply around 2013 and accelerated rapidly. By 2016, fentanyl was involved in more than half of all opioid overdose deaths nationally. By 2021, synthetic opioids — primarily fentanyl — were responsible for more than 70,000 of the 107,000 total drug overdose deaths recorded in the United States.^4^

What the Legal Reckoning Actually Produced

Purdue Pharma filed for bankruptcy in September 2019 following thousands of civil lawsuits from states, cities, counties, and tribal governments. In October 2020, Purdue Pharma and Sackler family members agreed to plead guilty to federal criminal charges — marketing fraud and anti-kickback violations — as part of an $8.3 billion settlement, one of the largest in American history. The settlement was restructured through the bankruptcy process in subsequent years amid disputes about whether individual Sackler family members should be shielded from future civil litigation. The Sacklers personally agreed to pay approximately $6 billion to settle civil claims. Several family members had transferred billions of dollars from Purdue to personal accounts in the years leading up to the bankruptcy — transactions that litigation sought to recover.^1^

Purdue Pharma is in bankruptcy and OxyContin’s brand is effectively destroyed. The opioid crisis it helped ignite has evolved far beyond the original prescription drug problem into a fentanyl crisis that no longer depends on pharmaceutical marketing or prescriptions. More than 500,000 Americans died from opioid overdoses between 1999 and 2019, according to the CDC — a casualty count that exceeds American military deaths in World War II. The company that started the fire has been dissolved. The fire has not. The meth-and-opioid story and the drug war’s enforcement failures are two sides of the same American drug policy failure.

─────────

Sources:

1. Macy, Beth. Dopesick: Dealers, Doctors, and the Drug Company That Addicted America. Little, Brown, 2018.
2. Quinones, Sam. Dreamland: The True Tale of America’s Opiate Epidemic. Bloomsbury, 2015.
3. Centers for Disease Control and Prevention. Drug Overdose Deaths in the United States, 1999–2021. CDC NCHS Data Brief, 2022.
4. Department of Justice. Purdue Pharma L.P. and Its Affiliates Plead Guilty. Press Release, October 21, 2020.
5. Keefe, Patrick Radden. Empire of Pain: The Secret History of the Sackler Dynasty. Doubleday, 2021.