The devastation caused by opioids in the US is on a truly staggering scale. Opioids kill more than 100,000 people a year. As we know from Patrick Radden Keefe’s book on the Sackler family, Empire of Pain, legal opioid manufacturers knew full well their products were dangerously addictive, but pushed them on the public anyway. A new study has been released in the British Medical Journal that examines the business practices of one of the most important opioid manufacturers, Mallinckrodt, who for reasons unknown have escaped the kind of infamy reserved for the Sacklers and Purdue Pharma. This essay is about the way medicine is subverted to serve the profit motive—with deadly consequences.
Mallinckrodt. You’ve probably never heard of them. The name hardly rolls off the tongue like “Purdue Pharma,” does it? But if you know about Purdue Pharma and oxycontin—about how millions of Americans were deliberately hooked on prescription opioids and how hundreds of thousands died, and are still dying—you should know about Mallinckrodt, because they’re just as responsible as the infamous Sackler family, if not more.
There isn’t just one “empire of pain” in the US, to borrow the title of Patrick Radden Keefe’s devastating book on the Sacklers: there are multiple empires, and for a time Mallinckrodt was the biggest and the worst of all. The empire of empires, if you will.
Between 2006 and 2012, Mallinckrodt, not Purdue Pharma, was the single largest producer of prescription opioids in the US. During that period, they saw sales of $12 billion or c.40% of all opioid pills on the US market. Their baby-blue oxycodone 30mg tablets became an icon for the trail of destruction opioids cut across America, and especially its poorer regions like the mountain communities of Appalachia. The branding was so strong that M30 knockoffs laced with fentanyl, in that signature baby blue, are a fixture of the illegal street trade even today.
Like Purdue, Mallinckrodt was made to pay big—but hardly big enough—for its role in America’s opioid crisis, reaching a settlement of $1.7 billion with the US government, in 2022. Or rather, that’s what was supposed to happen. Mallinckrodt has since filed twice for bankruptcy and repeatedly missed settlement payments of hundreds of millions of dollars. They may never pay the full amount, or anything near it.
For whatever reason, unlike Purdue, Mallinckrodt were willing for internal documents related to their opioid products to be released to the public as part of their official settlement. Perhaps Mallinckrodt thought the sheer volume of company documents—some 1.3 million—would prevent a thorough examination of their business practices. But even a cursory analysis is enough to reveal some very ugly truths about the way the company marketed and sold its products.
Two university academics from Canada and the Netherlands recently looked in depth at 900 Mallinckrodt contracts, and their findings have now been published in the British Medical Journal, under the title, “How an opioid giant deployed a playbook for moulding doctors’ minds.” The authors outline a deliberate strategy they call “the ghost management of medicine,” in which Mallinckrodt kept a stable of paid scientists and physicians, euphemistically referred to as “key opinion leaders,” and used them to craft narratives that would distract physicians from the mounting pile of human wreckage they could see, or should have seen, right in front of their eyes.
As the noughties drew to a close, there was already serious concern about the extent of opioid addiction in the US. Purdue had settled charges of fraudulent marketing with a payout of $600 million, and the FDA had introduced new rules requiring opioid makers to educate healthcare providers, doctors and patients about the nature of opioids and their risks. Magazines and newspaper ran stories about “addiction by prescription” and described pharmacies as glorified “pill mills” dispensing drugs like oxycontin and oxycodone without a second thought for the consequences.
Mallinckrodt had other ideas. They wanted to sell even more opioids and, in particular, they wanted to bring to market a new class of stronger, extended-release opioid. They devised a strategy targeting 10,000 physicians across the US, with the aim of reaching nearly 90,000 designated “prescribers”—medical professionals prescribing Mallinckrodt opioids—by 2017. To do this, Mallinckrodt had to allay fears about opioid addiction, and this is where their network of “key opinion leaders” came in.
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