The Man-made Opioid Epidemic: Part 4 – The Linchpin.

Posted on | December 1, 2015 | Comments Off on The Man-made Opioid Epidemic: Part 4 – The Linchpin.

Bronze Linchpin,Zhou Dynasty, China

Mike Magee

In the first three segments of this 5-part series, The Man-Made Opioid Epidemic, I have defined the crisis, the shared responsibility, and the growth of Prescription Drug Monitoring Programs (PDMPs) as a counter-balance to pharmaceutical data mining and marketing, which have been a shared venture of pharmaceutical and medical organizations for the past 60 years

I have also suggested that the recently documented bending of the survival curve of middle aged white males in America reflects a broad systemic problem, anchored by a deeply conflicted and financially interdependent Medical Industrial Complex.

Since World War II, this cabal has been transferring financial and human resources back and forth across the porous boundaries of academic medicine, government and the pharmaceutical industry. Along the way, leadership and regulatory bodies, like the AMA, the FDA, and the NIH, on whom our nation has depended to maintain a balance of power and legitimacy in all things science, have rationalized a steady and slippery slide, dismantling protective boundaries and diverting attention when necessary, in the interest of parochial organizational gain and individual career advancement.

In this regard, opioid over-prescribing is simply a symptom of a much larger problem which is many decades old, of which all are aware, and which nearly all have chosen to leave unaddressed. Central narratives have been carefully rewritten to emphasize the laudable goals of scientific progress and philanthropy, while largely expunging the driving instinct and natural tendencies of many individuals to aggressively pursue fame and fortune. No greater example exists of this strategy than that of Arthur Mitchell Sackler, the founding funder and benefactor of what would become Purdue Pharma, the producer of Oxycontin.

The official narrative, as it exists today, oft repeated by premier medical and cultural organizations, who maintain schools, exhibit halls, and colloquia that bear his name, features:

1. A remarkably industrious boy who, from an early age, supported his parents (who lost everything in the Depression), put himself through college and medical school at NYU, doing the same for two younger brothers who sought medical school overseas to escape prejudice.

2. A boy who grew up in “hard times”, whose parents were grocers in Brooklyn, chose medicine as a vocation at the age of four, but whose passion drew him more than equally to Art, pursuing art and sculpture lessons as a teen, and taking courses at New York’s famed Coopers Union while attending college and funding the family besides.

3. A committed physician and researcher who generated 140 science related papers, dealing primarily with exploring biologic approaches to psychiatric illness in the 1950’s.

4. A remarkably prolific philanthropist focused on brand name institutions in Medicine and the Arts.

5. A very successful business man, whose extended family fortune was pegged in 2015 , at $14 billion, 18 years after his untimely death at age 73 from a heart attack.

All of this is largely true. Yet, the details that tie Arthur M. Sackler to the Man-made Opioid Epidemic, and the well established tactics that helped consummate the Medical Industrial Complex in the second half of the 20th century are equally true, but somewhat hidden from public view. What is the full picture?

Arthur Sackler was born in 1913, the son of immigrants, his father from the Ukraine, his mother from Poland. They lived in Brooklyn. By all accounts their son, who attended the famed Erasmus Hall High School, was both intelligent and industrious.

Erasmus Hall High School, 1930

A statue of the school’s namesake was erected in 1930 and sits in the school’s courtyard. An accompanying inscription, which likely inspired the young Arthur, graduating that same year, read, “Desiderius Erasmus, the maintainer and restorer of the sciences and polite literature, the greatest man of his century, the excellent citizen who, through his immortal writings, acquired an everlasting fame.”

By 1937, (even while narratives suggest he was functioning as a significant source of financial support to parents, siblings, and self), he completed both college and medical school in record time, and married his first wife, Else Finnich Jorgenson. Three years later, in 1940, after completing an internship at Lincoln Hospital, he adjusted his career path and was already wealthy enough to begin to seriously collect art. He was now a pharmaceutical managing director, and head of the Medical Research Division at Schering Corp., a American based subsidiary of German parent, Schering A.G., established “in preparation for its assignment of supplying and holding the foreign markets of Schering A.G. for the duration of the anticipated hostilities”.

His role as head of the Medical Research Division apparently included medical affairs. During Medical School, he had earned his keep doing “medical editing”. One organization listed as a client was The Association of Medical Students and its journal. By 1940, we are able to see the first concrete indication that Arthur has become accomplished in the art of Public Affairs and Medical Communications. In that year, on behalf of Schering Corp, he presented an endowment check at the Annual Convention of The Association of Medical Students. The funding was to fully support a new award program called “The Schering Award”, to encourage student interest in the burgeoning field of endocrinology – central to Schering current product line.

Two years later, the award and Schering Corp., were gone, seized by the US government with other “German interests”. It would be another ten years before the government released the 440,000 shares of Schering stock being held, and allowed the company to once again function independently.

Arthur used that decade well. With Schering gone, he joined the William Douglas MacAdams Advertising Agency in 1942, and by 1947 gained a controlling interest in the firm. At the same time, with a healthy understanding by now of medicinal chemistry, he decided to pursue the growing field of Psychiatry and enrolled in the New York residency program at Creedmore Mental Institution on Long Island. The specialty was getting a huge boost from the war effort. U.S. Army head of Psychiatry, William Menninger, was systematizing the treatment of “Shell Shock” including the liberal use of barbiturates. His playbook, Medical 203, would become the basis of DSM 1 in just a few years, and launch the medicalization and pharmacologic treatment of mental illness.

By 1949, Arthur not only controlled his own Medical Advertising Agency and had completed his training, but had now established, with his two brothers, Mortimore and Ray, the Creedmore Institute of Psychobiological Studies. Experimenting with a variety of agents, including sex hormones and histamine, on patients with psychosis, they began to churn out papers advancing their theories on the biologic basis of treatment for psychiatric illness. There was no scarcity of research subjects. Creedmore by now, in the post-war period, had over 7000 occupants. In 1949, as well, he married his second wife, Marietta Lutze, the third generation manager of the German Pharmaceutical firm, Dr. Kade. All the time, Arthur had been ramping up his art collecting, now focused heavily on Asian artifacts. And as luck would have it, he was flush with cash. The Antibiotic Era was in full bloom.

Between 1950 and 1957, advertising revenue in JAMA for broad spectrum ads increased seven-fold. At the top of the list was Pfizer and its new antibiotic, Terramycin. Between 1950 and 1952, 68% of all JAMA broad spectrum ads were funded by Pfizer. Between 1952 and 1956, nearly every JAMA issue included Pfizer’s in-house magazine titled “Spectrum”. The push paralleled an increase in Pfizer detail men from 8 to 2000 (including medical students). They targeted doctors and hospital pharmacies, and developed a sophisticated range of CME materials for the first time. Pfizer’s agency of record? The William Douglas MacAdams Advertising Agency. The principal on the account? Arthur M. Sackler.

Arthur’s groundbreaking innovations would, in the future, be enshrined in the Medical Advertising Hall of Fame. In the posthumous award, they stated, “In the late 1940s and 1950s, Rx companies were not marketing-oriented. They had small field forces and lacked extensive marketing resources. At this time, however, scientific breakthroughs in steroids, antibiotics, antihistamines, oral hypoglycemics, and psychotropics were revolutionizing medicine and creating a highly competitive market for brand-name prescription drugs. Dr. Sackler saw the important role non-personal selling could play in this environment and became an advocate for the full-blown marketing programs (field force plus multimedia promotional activities) employed today….It can be said that Dr. Sackler helped shape pharmaceutical promotion as we know it today (he even experimented with medical radio and TV in the 1950s), as well as established the role of communications and promotional programs in pharmaceutical marketing.”

The Hall of Fame also acknowledged that he used his psychiatric training quite effectively. As they said, “Dr. Sackler was a psychiatrist who published 140 scientific papers on neuroendocrinology, psychiatry, and experimental medicine. His experience in those fields enabled him to position different indications for Roche’s Librium and Valium—to distinguish for the physician the complexities of anxiety and psychic tension. Accordingly, Valium became the first $100 million drug, a then staggering sales figure.”

What they failed to mention, in 1997, perhaps intentionally, a decade after his death, was the fact that, in 1952, their honoree provided funding to allow the purchase of a fledgling New York based pharmaceutical firm, Purdue Frederick Co. which initially focused on antiseptics like Betadine and laxatives like Senokot. But within a decade, they went shopping overseas and purchased Napp Pharmaceuticals in the UK.

Napp owned the patent to several sustained released technologies, initially used for asthma treatment. But in the years ahead, with the Hospice movement arising at St. Christopher’s in London, the Sackler’s supported the development of the first sustained released morphine, MSContin, in 1984, three years before Arthur’s death. Its progeny, 11 years into the future, would be the firm’s notorious Oxycontin. Following Arthur’s playbook, the drug would be heavily markeded by a collection of paid “pain specialists” to gullible generalists as addiction proof.

If the Hall of Fame missed this fact, they more then made up for it in touting one of the jewels of Sackler’s vertical integration scheme, the Medical Tribune. Of this, they said, “He developed a newspaper house organ called Scope for Upjohn. In 1960, based on this model, he began publishing Medical Tribune, which, in time, became a major scientific publication reaching over a million physicians each week in 20 countries.”

Primarily an advertisement cash cow, his editorials supporting free enterprise and scientific progress, and promoting friends while critiquing foes, brought glowing praise in his obituary from many medical luminaries of his own wholly controlled subsidiary. For example, his friend Michael DeBakey said, “In many ways, Medical Tribune is probably the best medical publication in the English-speaking world. It is regarded in many respects as the best way to keep up with what is happening in medicine.”

Scratching at the surface of Arthur M. Sackler’s narrative reveals the rather staggering challenge we face in addressing the systemic issues underlying what appear to be isolated occurrences like the current Man-made Opioid Epidemic. Here in one individual – whose praise and awards, bestowed so luxuriously by the highest levels of American Science and Medicine, in equal measure to the resources he provided to these very same bodies – can be observed the full tangle that is the Medical Industrial Complex.

Over a period of a half century, under the title of beneficent physician, Arthur Sackler built a vertically integrated empire that created pharmaceutical demand, magnified and multiplied it, and then sold into it as it rose. And at every step along the way, he was aided and abetted by those who coveted the Sackler brand. In 2001, his third wife, Jill Sackler, was present to celebrate the Inaugural Arthur M. Sackler Colloquium on Neural Signaling held at the National Academy of Sciences in Washington, DC, February 15–17, 2001. Johns Hopkins neuroscientist and psychiatrist Solomon H. Snyder delivered the remarks. He said, “ The Sackler colloquia are predicated on the notion that creativity in science is fostered by vigorous interactions among scientists.” Eleven years later, his institution produced “The Prescription Opioid Epidemic: An Evidence Based Approach” which actively raised the question whether our style of medicine and prescribing has become too “creative” and “vigorous” for our own health.

In part 5, the final concluding segment of The Man-made Opioid Epidemic, I will describe the difference between prevention and intervention in addressing opioids and pharmaceutical prescribing practices.