The healers who prescribed the poison that helped unleash the opioid epidemic

Dr. Russell Portenoy stood before rooms of physicians in the late 1980s and 1990s, telling them what they desperately wanted to hear: that the pain their patients suffered was undertreated, that opioids were safe, and that withholding them was cruel.

“I gave innumerable lectures in the late 1980s and ‘90s about addiction that weren’t true,” Portenoy later admitted.

By then, the damage was done. Opioids had become the most common cause of preventable death in America. As of 2011, the United States — with 5% of the world’s population — consumed 75% of the world’s opioid prescriptions. From 1999 to 2014, prescriptions quadrupled. More than 165,000 people died from opioid overdoses in that period alone.

The question that haunts the medical profession is not whether the opioid crisis happened. It is how the people who took an oath to “do no harm” became the primary distributors of a catastrophe.

The fragile foundation

The scientific basis for the opioid prescribing revolution rested on a single paragraph.

In 1980, Dr. Hershel Jick published a 101-word letter to the editor in The New England Journal of Medicine reporting that addiction was rare among hospitalized patients treated with narcotics. Time magazine called it a “landmark” study. It was not a study at all. It was a letter, based solely on hospitalized patients, and Jick repeatedly stated it had been misinterpreted.

Dr. Kathleen Foley, a pioneering pain specialist at Memorial Sloan Kettering, published two influential articles in 1981 and 1986 reporting low addiction rates in small groups of cancer and non-cancer patients. As the American Journal of Public Health later noted, these articles “became the rather fragile foundation of a 20-year campaign for the long-term use of opioids in chronic noncancer pain”.

There were “no published long-term data” on addiction rates among chronic pain patients, Foley acknowledged. There had been no long-term controlled studies of opioids for chronic pain at all.

The absence of evidence became the basis for a revolution in medical practice.

The money behind the message

Portenoy and his pain center received millions in funding from pharmaceutical companies, including Purdue Pharma, the maker of OxyContin, as well as Mallinckrodt, Wyeth, Baxter and Pfizer. He admitted to financial relationships with more than a dozen companies, most of which produced opioid painkillers.

Portenoy defended himself with a statement that has become emblematic of the era’s ethical blind spot: “My viewpoint is that I can have these relationships [and] they would benefit my research mission and to some extent they can benefit my own pocketbook, without producing in me any tendency to engage in undue influence or misinformation”.

The manufacturers spent $166 million in 2014 alone on detailing branded opioids to doctors — twice what they spent in 2000. Purdue accounted for $108 million of that total. Sales representatives made hundreds of thousands of one-on-one visits to doctors, “to disseminate their misrepresentations in targeted, one-on-one settings that allowed them to promote their opioids and to allay individual prescribers’ concerns”.

The Sackler family, which owned Purdue, monitored these efforts with obsessive attention. Court documents allege the Sacklers tracked the exact number of sales visits, approved compensation for representatives, and received detailed reports on the “Return on Investment” gained from paying doctors to promote Purdue’s drugs.

They also directed a strategy to “push patients to higher doses of opioids which are more dangerous, more addictive, and more profitable”.

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Institutions amplified the message

Physicians did not encounter these claims in isolation. They were reinforced by the institutions that governed medical practice.

The Joint Commission, which accredits hospitals and whose standards are recognized in state law, promulgated the concept that pain is the “fifth vital sign. ” A U. S. Government Accountability Office investigation found that the commission’s pain management education programs were funded and co-authored by opioid manufacturers, and that the partnership with Purdue “may have facilitated its access to hospitals to promote OxyContin”.

The American Geriatrics Society received at least $344,000 from opioid manufacturers since 2009. In 2009, it issued guidelines recommending that “all patients with moderate to severe pain. . . should be considered for opioid therapy,” making “strong recommendations” despite “low quality of evidence”. Those guidelines have been cited as many as 1,833 times in scholarly literature.

The Federation of State Medical Boards wrote rules that put pressure on physicians to treat pain aggressively. Hospital lawyers warned doctors their patients could sue them if they did not treat pain adequately.

The message to physicians was clear: prescribe, or risk professional and legal consequences.

The physicians who complied

Some prescribers were corrupt. The pharmacist Dan Schneider, whose son was killed by a drug dealer, began investigating a local doctor, Jacqueline Cleggett, whose signature appeared on the vast majority of OxyContin prescriptions coming across his counter — often for young, healthy patients at high doses. Cleggett eventually pleaded guilty to illegally dispensing controlled substances.

But the more troubling figure is the ordinary physician — the well-intentioned general practitioner who believed the research, trusted the guidelines, and wrote prescriptions in good faith.

“Overstressed and well-intentioned general practitioners, and a number of unscrupulous ‘pill mill’ operators, wrote liberal prescriptions for the new analgesic,” the American Journal of Public Health noted.

These physicians were not villains. They were professionals responding to the incentives and information their institutions provided. The pharmaceutical companies funded the research. The medical societies wrote the guidelines. The accrediting bodies defined the standards. The government regulators approved the labels.

Each institution did its part. The physicians did theirs. And the patients died.

The reckoning that never came

Portenoy eventually recanted. “I gave innumerable lectures in the late 1980s and ‘90s about addiction that weren’t true,” he said. Yet he remained chairman of the pain clinic and palliative care clinic at Beth Israel Medical Center.

Richard Sackler, in a 2015 deposition, said he did not believe Purdue’s conduct or its marketing of OxyContin caused the addiction crisis. Purdue filed for bankruptcy in 2019. In late 2020, a federal judge approved an $8. 3 billion settlement after the company pleaded guilty to three felony counts.

The Sackler family agreed to forfeit roughly $225 million of personal wealth and dissolve the company. Purdue made nearly $20 billion in profits directly related to OxyContin.

The physicians who prescribed the drugs faced no comparable reckoning. They were following the standard of care. They were treating pain. They were doing what the experts told them to do.

What the cognitive dissonance reveals

The opioid crisis was not caused by a conspiracy of evil doctors. It was caused by a system in which the pursuit of profit was laundered through institutions of expertise, and in which well-meaning professionals were given every reason to believe they were healing while they were harming.

The physicians who prescribed opioids did not experience themselves as agents of state violence or corporate profit. They experienced themselves as compassionate. The pharmaceutical companies cultivated this self-perception deliberately. As one academic analysis puts it, opioid manufacturers exploited “hope” — the physician’s hope of relieving suffering, the patient’s hope of living without pain — to manipulate prescribing behavior.

The limits of professional ethics in a market economy are revealed in this gap: between what physicians believed they were doing and what they were actually doing. Professional ethics told them to treat pain. Market incentives told them to prescribe opioids. The two messages were aligned, and the alignment made the harm invisible.

The healers could not see the poison because the system had relabeled it as medicine.