Hi I’m Annabelle Timsit, a Quartz journalist who uncovered how the US opioid marketing playbook is going global after investigating Mundipharma, the international arm of US-based Purdue Pharma. Ask me anything!

Why doesn't anyone talk about how much these medications have helped people? I am so glad I had these drugs post surgery. My ex had to endure huge amounts of cancer radiotherapy and without Oxycontin and Duragesic patches she wouldn't have kept her sanity.

We talk about that a lot in our documentary! It's important to highlight the fact that opioids are a useful tool to treat some types of pain, including short-term acute pain associated with surgery. But science shows they're just not effective at treating long-term chronic non-cancer pain, though many pharmaceutical companies said they were, and that led to a lot of misuse and abuse.

That doesn't seem to be the narrative any more. It's about destroying the companies that make these pain killer's now. What happens when they're banned or no one wants to make them anymore?

As long as there's a market of people who need them and are willing to pay for them, there will still be companies who will make them. To my knowledge, no government or regulatory agency has talked seriously about banning opioids altogether; rather, it's about regulating them better, being transparent about what they can and cannot do, and training doctors to prescribe them more responsibly.

Does anyone at Purdue/Mundipharma feel bad/guilty for this?!?

Yes! We interviewed a former Purdue sales rep in the US who later became a whistleblower and she's talked about how she was made to downplay the addictiveness of opioids to doctors and "interpret objections as a buying signal." And there have been other whistleblowers too (see here: https://news.bloomberglaw.com/federal-contracting/oxycontin-fraud-case-jeopardized-by-whistleblowers-death).

Russel Portenoy, one of Purdue's "key opinion leaders" in the early 2000s, is testifying against the industry in exchange for being dropped from several lawsuits (This is a good explanation of his background: https://www.bloomberg.com/news/articles/2019-04-08/opioid-evangelist-switches-sides-in-case-alleging-pharma-abuse).

Hi! I am very interested in how such a huge research can be lead. How did you get financed so you could investigate for a year? Also, how did you succeed in getting interviews about such a touchy subject? And I mean, interviews that lead you somewhere, not someone spurting out whatever PR told them to. What is your educational background and did it help you conducting all this? Did you or the people you interviewed get in trouble? Sorry if that's too many questions.

Hello! Not at all, thanks for asking.

I was lucky enough that Quartz supported me in doing this year-long investigation in parallel with my other work as a staff writer. I don't have a scientific background but I've been interested in the opioid epidemic for a long time and had done a lot of research on it on my own, and that helped.

As for the interviews, I would say we pretty much got the standard PR-friendly response from Mundipharma itself, but we did manage to speak to a consultant who's worked for Mundipharma, and he was pretty open with us about his industry-sponsored promotion of opioids as a treatment for chronic pain. And we spoke to the head of a pain patient group, who seemed to almost change his mind about pharmaceutical marketing over the course of a three-hour-long interview. By the end, he told us: "People should be aware that advertised stuff is only used to sell the stuff. And it's not to provide an honest and open view on what the stuff is actually capable of doing."

That is really interesting. If you one day you publish anything about how you lead the investigation, I would be very interested to say so. Also, I'm glad some media are still open to support such long term projects like yours.

Thank you! If you're curious to learn more, you can read a writeup of our premiere event in New York City here: https://qz.com/1692463/how-an-er-doctor-and-a-purdue-pharma-whistleblower-think-about-the-opioid-crisis/

And if you'd like to become a Quartz member and support our journalism, we often do phone calls where we talk about our reporting process and more with members. The membership conference call for the documentary is here: https://qz.com/1696217/watch-our-video-conference-call-about-the-global-spread-of-opioid-pain-killers/

Statistically the Opioid crisis is a distant third to the ongoing tobacco and alcohol crisises. Why do Opioids deserve more attention than these other two drugs that have greater societal costs?

I don't believe that's the case. I think (hope!) there's enough attention to go around for all three—and more.

What don't you believe is the case?

I don't believe the opioid crisis deserves more attention than tobacco and alcohol addiction. I think there's enough attention to dedicate to all of these problems.

Gotcha. Thanks for clarifying. Was there anything you learned that truly surprised you?

No problem! And yes, definitely. I assumed that there were very few problems with opioid misuse in Europe, given what I thought I knew about the strict public health regulations there and the oversight strength of the public healthcare system. But I was wrong. In June, the OECD reported finding “growing, problematic opioid use” in Sweden, Norway, Ireland, England, and Wales. In France, prescriptions of oxycodone to treat chronic non-cancer pain increased by 1,180% between 2004 and 2017. Obviously, nothing like the scale of what we're seeing in the US, but still, these are problematic signs, as all the public health experts I spoke to told me.

What was the biggest thing you discovered/saw that just made you speechless?

When I heard a Mundipharma-paid consultant (and former team leader for access to controlled medicines at the WHO!) repeat the debunked claim that the risk of addiction for chronic pain patients who take opioids long-term is less than 1%, I sort of gasped internally.

Why did you gasp? There are many studies that show the rate at less than 1% and the only ones that put it any higher are misquoted. There's one that puts it at 8%, but if you look at the source material, its 0.8%. So why are you so aghast? Do you have any material that puts it higher, or are you just going with your own personal beliefs?

During the course of our reporting we spoke to more than a dozen medical experts, and none of them told us that the risk of addiction was less than 1%. Most gave a range of anywhere between 7 to 12%.

I'm not sure which study you're referring to, but the National Institute on Drug Abuse (NIDA) cites a range of 8-12% (https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis), which comes from a 2015 review done by Vowles et al: https://idhdp.com/media/400537/rates_of_opioid_misuse-_abuse-_and_addiction_in3.pdf

Has there been any Purdue Pharma employees who feel no remorse for what they're doing?

I'm not sure about that, but I can tell you there are some employees (especially in sales) who felt uncomfortable enough that they later became whistleblowers and spoke to authorities and the media about Purdue's misleading marketing of opioids.

Wow, you're doing an amazing job covering such an important story.

Thanks very much for your interest!

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I like grey and blue!

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That's a lovely image!

Do you think that there will be any tangible justice?

I think the opioid litigation in the US is shaping up to be really historic, but there are concerns that, even if states win a significant settlement from opioid manufacturers, they might not use the money in the most effective way to help people addicted to opioids get access to treatment (which is really expensive).

There's precedent for this if you look at where the money states got (and continue to get) from Big Tobacco went: https://news.bloomberglaw.com/health-law-and-business/squandered-big-tobacco-money-a-cautionary-tale-in-opioid-cases

Is there a possibility that opioid manufacturers invest in addiction treatments?

Yes. For example, Purdue has donated some money to a nonprofit firm developing a cheaper version of Narcan, the opioid-overdose antidote made with naloxone. And money from drug companies in the opioid settlement is meant to go towards funding addiction treatment for victims of the opioid epidemic. https://www.bloomberg.com/news/articles/2018-09-05/opioid-giant-purdue-will-fund-nonprofit-overdose-antidote-maker

Are the drug companies profiting on any of these investments?

Stay tuned for more reporting on this from me!

I guess I was hoping we would see people responsible get jail time - wouldn't that be a bigger deterant than for a company to pay fines they likely budgeted for and individuals to receive 'a slap on the wrist'

It's oftentimes difficult to establish individual responsibility in cases like these. Recently though, and for the first time, federal authorities charged two former executives of Rochester Drug Cooperative, one of the largest pharmaceutical distributors in the US, with drug trafficking, which is a criminal charge. It'll be interesting to see if anything similar happens as a fallout of the larger opioid litigation. https://www.nytimes.com/2019/04/23/nyregion/opioid-crisis-drug-trafficking-rochester.html

Purdue makes no difference overall. Other pharma firms are already producing similar drugs that have been on the market for years. Do you think the "marketing playbook" is unique to any other product's marketing. Do you realize that opioids give millions relief from pain and suffering when used as prescribed? Do you realize no one trusts journalists because of the ridiculous/embarrassing level of bias and false reporting?

Hello! In our documentary we explain in detail that opioids are a useful tool (when used appropriately) to help millions of people who suffer from pain. And we also point out that, in too many parts of the world, people who need opioids can't get access to them.

But there's not a lot of evidence that opioids work well for people who suffer from long-term chronic pain that isn't tied to cancer or other life-threatening illnesses. On the other hand, there is evidence that opioids are a lot more addictive for chronic pain patients than the pharmaceutical industry alleged for years. So we believe it was worth looking into whether this type of misinformation was happening outside of the US as well. Turns out, it was.