‘The crisis was manufactured’: inside a damning film on the origins of the opioid epidemic
The origin of America’s opioid crisis – the ludicrously profitable proliferation of addictive pain medications whose abuse killed nearly half a million Americans between 2000 and 2019 – arguably comes down to a single sentence. In 1996, the drug company Purdue Pharma, then owned and controlled by Mortimer and Raymond Sackler and their heirs, began selling the opioid drug OxyContin. (The family of a third brother, Arthur Sackler, sold their shares before OxyContin’s introduction.) The highly addictive medication was designed for people with severe pain, such as cancer patients, but went to market as a moderate pill for chronic pain sufferers, complete with a succinct, misleading seal of approval from the Food and Drug Administration: “Delayed absorption as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.”
The seal was “a phrase that gives rise to the opioid epidemic,” says Patrick Radden Keefe, a New Yorker journalist, author of the book Empire of Pain: The Secret History of the Sackler Dynasty, in the HBO documentary The Crime of the Century, film-maker Alex Gibney’s expansive four-hour dive into morally bankrupt businesses which fueled the crisis. It was also a lie, one Purdue used as a catch-all shield to aggressively market OxyContin to doctors across the country as a safe prescription for chronic pain sufferers. Depositions from subsequent lawsuits revealed that Purdue Pharma never held clinical trials to demonstrate that OxyContin was less addictive or likely to be abused than any other opioid. A 2006 memo prepared by prosecutors in the Western District of Virginia, not revealed until August 2019, found that the FDA official in charge of the approval, Dr Curtis Wright, had a suspiciously “informal in nature” relationship with the company; Wright stepped down from the FDA shortly after OxyContin’s approval and, a year later, took a job at Purdue with a $379,000 annual salary, roughly triple his previous pay.
“There is no opioid crisis without OxyContin,” Gibney told the Guardian. And there’s no OxyContin boom without deceptive marketing, which The Crime of the Century uses as its starting point for a critical reframing: what if we thought of opioids in the US not as a passive crisis, but the logical result of a series of legal and ethical crimes. (In October, Purdue Pharma, now in bankruptcy, pleaded guilty to three federal criminal charges, including delivering misleading information to federal agencies, and agreed to a settlement of $8bn; none of the Sackler family members were charged.)
The word “crisis” conjures the images of natural disasters, unpreventable harm – “a flood, or a hurricane, and isn’t that terrible, but there was nothing we could do about it, it was just something that happened,” says Gibney. But “once you reframe it as a crime, then you begin to look – what was the motive for the crime? What was the crime, how was the crime conducted, and who’s responsible for the crime?”
“You can find a reason for what happened, and attempt to both reckon with accountability, as well as changing the system that made it possible,” says Gibney. In the case of opioid addiction and abuse in the US, “the crisis was manufactured. It was not something that just happened.”
The Crime of the Century digs into the many tentacled mess of profit incentives, political apathy, and astoundingly callous greed underlying the business of opioids, which poured millions of pills into overwhelmed towns while netting pharmaceutical companies billions of dollars. The first two hours traces the rise of OxyContin, which rode the sometimes wellintentioned, Purdue-supported wave of pain as the new “fifth vital sign”; and Purdue Pharma’s cynical profit strategy – underplaying OxyContin’s potential for abuse, ignoring distress calls from sales reps and doctors in the field about the burgeoning addiction crisis, and cynically pushing the line that OxyContin was safe at even absurd levels.
The second hour picks up where the OxyContin flood left off: the rise of fentanyl, a synthetic opioid 80 to 100 times the strength of morphine that is responsible for tens of thousands of overdose deaths. It zeroes in on the fraudulent marketing of Insys Therapeutics, whose billionaire founder John Kapoor was found guilty in May 2019 of bribing doctors and defrauding insurance companies for its fentanyl drug Subsys – a rare instance of individual business owners facing repercussions.
Both chapters include perspectives from numerous sides in the crisis, from those who have lost loved ones to opioids to former Purdue sales rep Mark Ross, who sounded the alarm on abuse in his home state of West Virginia as early as 2000. Former prosecutors who investigated Purdue and DEA agent turned anti-opioid crusader Joe Rannazzisi testify to calls for consequences ignored or minimized, while former Insys reps Sunshine Lee and Alec Burlakoff – convicted alongside Kapoor – explicate in detail a corporate culture which would produce a rap music video about fentanyl that boasts “I got new patients and I got a lot ‘em.”
Gibney is no stranger to prolific corruption, greed and incompetence, having documented Russian interference in American elections in last year’s Agents of Chaos, and the bungled federal response to Covid-19 pandemic in Totally Under Control. But it was a process for him to see the business of opioids as less passive crisis than criminal negligence. The “real eyeopener,” he said, was that 2006 Virginia prosecution memo, first excerpted by the New York Times in 2019, a damning 120-page document built on four years of research and millions of subpoenaed documents which essentially laid out the deceptive Purdue marketing strategy. Prosecutors found the company “trained its sales representatives” to use “false and fraudulent” claims about OxyContin, and recommended bringing felony charges against three top Purdue executives, Michael Friedman, Howard Udell, and Paul Goldenheim.
The felony charges never came; Purdue assembled a high-powered legal team – including future Trump advisor Rudy Giuliani – who reportedly convinced the Bush Justice Department to scrap the prosecution. Purdue pled guilty to felony misbranding and agreed to pay $500m – a paltry sum compared to its billions in profit, and a settlement which spared its executives of any charges. The following year, 2007, Purdue reported record profits, largely attributable to OxyContin.
“You see that the playbook for those crimes, the arguments for those crimes, gets repeated over and over and over again by a number of other companies,” said Gibney. “The failure to prosecute, the failure to hold people to account, leads other people to believe, ‘Well, OK, there’s not much risk to us then. If we get caught, then we’ll pay a speeding ticket and that’s just the cost of business.’”
The story of Purdue Pharma, now the target of several lawsuits across the country, and the marketing of fentanyl throughout the 2010s, demonstrate “the danger of putting together a turbocharged, unregulated 21st-century capitalism with healthcare,” says Gibney. “The profit motive so dominates everything that it creates a series of terrible incentives that are often adverse to the health of patients.”
“The opioid crisis is not the result of a few weak people, addicts of bad character who simply got hooked, and isn’t that too bad,” says Gibney. “What happened here is that big companies recklessly distributed dangerous drugs because it was profitable, not because it was good for the nation’s healthcare.”
A quarter-century on from the introduction of oxycontin to the market, with more than half a million Americans dead of overdose and many more lives shattered by addiction, the idea of resolution is, for many, impossible. What many who have endured the tragedy of opioids want, according to Keefe in the film, is not financial settlements but truth – the sales plans, the callousness, the information known or ignored, and when.
“That’s what we deserve – the truth about what really happened,” says Gibney. “And once we get the truth, then I think we can move to reform a system that’s badly broken.”
The Crime of the Century starts on HBO on 10 May with a UK date to be announced