Late last year, the Associated Press combined reporting with the Center for Public Integrity to roll out a multi-part series on the $880 million spent on lobbying and political contributions by the opioid industry in a decade long effort to stymie efforts to control these powerful drugs. Reporters reviewed of hundreds of documents brought to light in a recent court case and interviewed over 200 officials, experts, and advocates to understand how the opioid epidemic unfolded.
The series had its genesis when the AP’s Matthew Perrone tripped across a group called the Pain Care Forum. Led by the top lobbyist for Purdue Pharma, the Pain Care forum held regular meetings with doctor and patient groups in Washington to discuss strategies for ensuring Americans had easy access to opioids.
Last year, over 50,000 Americans died from drug overdose, and six out of ten were caused by opioids. That’s 91 Americans every day.
From Lake Atitlan, Guatemala where he is on sabbatical after 10 years at the Associated Press, Perrone spoke with me about what this award-winning series taught him about the political power of the opioid lobby and whether Americans can retain trust in medicine and our federal science agencies. Our conversation follows, condensed and edited.
This series has many of the classic elements of corruption that we see in the pharmaceutical industry—front groups, paid off physicians, incredible amounts of lobbying. But what seemed unique?
The story of American’s opioids crisis has two chapters from what I’ve seen in my reporting. The first chapter closed back in 2007. It was a classic pharmaceutical corruption story. This was when Purdue Pharma settled—excuse me—they actually plead guilty—and paid $600 million in fines. Usually companies settle and neither admit nor deny the allegations in the lawsuit.
You would think that would be the end of the story. But opioids are a bigger crisis than ever—so bad that they are reducing the lifespan of people in middle America.
I believe it is the first time we have seen a reduction in the lifespan of Whites in a century.
Right. So what happens after justice is supposedly served in 2007? The companies and their allies begin chapter two and put lobbyists on the ground in all fifty states. We found 1,300 of them. They also placed doctors and patient advocates they had paid on panels at the National Institutes of Health, on panels at the National Academies—defending more treatment of pain using opioids.
The companies created a whole new apparatus for pushing their drugs. I should add that these are legal means. It’s not illegal to lobby; it’s not illegal to give money to members of congress; it’s not illegal to push your favorite doctors to serve on federal panels.
In a way, that’s the saddest thing. It was all pretty much legal.
One of the things interesting about this 2007 settlement—it was one of the few times pharmaceutical executives were charged with criminal conduct and plead guilty. But these three executives only did a few years of probation and community service.
Nobody went to jail, and the behavior just continued. That’s what I find fascinating.
I don’t think we appreciated how into the nitty gritty, these companies are willing to get. A group called the Pain Care Forum was so worried about Washington state implementing new opioid guidelines that they hired a public relations firm for that one state. The American Pain Foundation also helped fund lobbing efforts.
In Tennessee, they have a very bizarre law that if a doctor is not willing to prescribe opioids for pain, he is required to send the patient to another doctor who will. That’s a law that the drug makers helped to pass and then defended in one of our articles.
Oxycontin generates over $2 billion in US sales. It’s not that much to hire a couple lobbyists in a state to protect millions of dollars in prescription revenue.
There’s an interesting story about how you uncovered the Pain Care Forum. How did that unfold?
I was talking with a source who had come to Washington for a meeting with the Pain Care Forum, which I had never heard of. This group meets once a month in Washington at a law firm, and it is run by the main lobbyist for Purdue. This source sent me a list of the attendees and it was all the companies and patient groups . . . anyone who had a stake in the matter of pain and opioids.
How did you get your hands on these documents? I had a sense from reading the stories that you had piggy backed on a lawsuit from Cohen Milstein.
In 2015, I learned that the City of Chicago had filed a lawsuit alleging something along the lines of what Big Tobacco had done. They accused opioid makers of polluting the public understanding of the benefits and risks of opioids.
That lawsuit made a big splash but few reporters caught on that the City of Chicago is a government entity with public record laws. That was the beginning of a trial and error process, trying to figure out what we could get. Like any overly ambitious reporter, I wanted all the documents. Well that didn’t work.
Eventually, I realized that you could get access to trade groups and nonprofits, and I remembered about the Pain Care Forum, and asked for those documents. They sent over a couple hundred documents, and I spent months organizing everything.
When I was on the Hill, I spent a great deal of time investigating the drug companies by investigating the doctors and nonprofits that the companies funded. I referred to them as the proxy agents of the companies. As you dig into these nonprofits, how does it change your idea of a “nonprofit”?
Yes. [Laughs]. I feel like we should almost come up with a new name because “nonprofit” sounds so innocuous and has so many connotations that don’t serve this conversation. I’m sure you remember the American Pain Foundation. They got 90% of their money from drug makers and then used that money to testify against people who were suing drug makers and to testify on Capitol Hill.
[Note to readers: after this interview, STAT reported on a new nonprofit called Advocates for Opioid Recovery which is calling for wider use of medications to treat opioid addiction. The group is advised by Newt Gingrich and Patrick Kennedy and has been promoted by CNN commentator Van Jones. All three declined to disclose the organization’s funding.]
I recently wrote a piece noting how one group created studies in science journals to push opioids.
Right. The American Pain Foundation shut their doors the next day after the Senate sent them a letter. Apparently, all that money dried up, overnight. To your point, many of these groups are messaging arms of corporate America. In this case, it’s the pharmaceutical industry, but there are similar innocuous sounding groups for banking and other industries.
What is your opinion of the federal agencies? The companies are doing what they do: creating front groups, paying off doctors, lobbying, creating medical studies as part of their marketing. Can Americans feel secure that their federal science agencies are still looking out for them, nonetheless?
Right. [Laughs] After this sabbatical, then I have to go back and keep writing about these agencies…. As citizens, you and I are very optimistic and idealistic when we think about our government. We should expect them to be crusaders for public health, the way that David Kessler was when he ran the FDA under President George H. W. Bush and President Clinton.
Unfortunately, it’s very easy to just check the box and say, “This meets the definition of a safe and effective drug.” But if you just think that small, you’re never going to stop an epidemic like the one we’re in. The ramifications of these drugs go so much further than just that one patient. Maybe they take it for five days after dental surgery and put it in their cabinet. Then along comes a nephew who finds the bottle and he takes it with his friends and they get hooked on opioids. A year later, this kid can’t afford to buy opioids illegally, so he starts taking heroin.
There are these cascades of impacts that make the conversations the FDA has over whether a company submitted well-controlled studies look out of touch. Nobody in the federal government was looking at the broader picture until the Centers for Disease Control came out with prescribing guidelines.
But the CDC almost had to sneak that out of their headquarters in Atlanta, before the drug companies could realize what was happening and stop it.
Absolutely. That’s the sad conclusion to our story. It took an agency hundreds of miles from DC that previously did not get in the business of writing medical guidelines. That’s not what they do. They track small pox outbreaks and epidemics. But the FDA had been locked into this narrative that we needed more opioids to address chronic pain.
It’s almost miraculous that CDC published those guidelines. We showed in one story how industry, once they got wind of what CDC was going to do, they succeeded in forcing them to delay the guidelines by a month. But against all odds, the guidelines came out largely intact.
What happened at the National Institutes of Health?
We have these august science groups that do important work, like the National Academies, like the NIH, but you have to realize that so much of that comes back to legislation. In the case of the Pain Care Forum, they wanted a semi-permanent body at the NIH that would do nothing but look at pain and push more money to studying it. Well, they got that in the Affordable Care Act, which was passed in 2010.
What do you know, the patient representatives and the doctors that ended up serving on that NIH panel had long standing relationships with the Pain Care Forum.
One panelist was a patient advocate whose chair at the Center for Practical Bioethics was created with a $1.5 million gift from Purdue. She has a permanent job, courtesy of Oxycontin.
I’m cracking up. I hadn’t thought of that before, but you’re right. She has a job courtesy of the profits generated by Oxycontin.
You would think that this would be a red flag, and agencies would go, “No. We cannot have this on our panel!” It makes you question what comes out of these supposedly august federal science bodies that we put so much faith and trust in, when they choose someone like this as an acceptable expert.
Explain what happened at the National Academies, this purportedly important scientific organization that advises the federal government on policy.
The National Academies has put out some great reports, but it comes down to someone in Congress requesting them. The Pain Care Forum had been working for years to have the National Academies write a report on pain in America. And this got into the Affordable Care Act.
You know how this works—the National Academies creates a committee with researchers from universities all across the country. We looked back and half the experts who served on that committee had connections to industry and the Pain Care Forum. In short, they lobbied for the creation of the report and then had their friends serve on it.
Surprise, surprise, the report came out and the first sentence was that “100 million Americans experience chronic pain.” One hundred million Americans, to put in perspective, is about 40% of adults. [Laughs] That’s a damn lot of pain.
They didn’t say it all needs to be treated with opioids, but the report could then be reinterpreted and promoted by the same nonprofits and companies to say that there can’t be restrictions placed on opioids, because there are 100 million people with chronic pain that need treatment.
When these conflicts of interest were first broke by the Milwaukee Journal-Sentinel and MedPage Today, the head of the Institute of Medicine wrote to MedPage Today asking if the outlet would “bar your reporters from writing about alcoholism because you receive advertising revenue from beer companies?”
I actually emailed Ivan Oransky, the editor, to confirm that the letter was real. I didn’t believe that someone like the head of the Institute of Medicine couldn’t understand that stacking a report with experts tied to industry might be a problem.
Who do you think does their background checks? It must be the last thing they do.
I don’t think they do much at all. Okay, so we have this giant organism called the Pain Care Forum, whose entire reason for existence is to consume money from pharmaceutical companies and convert that cash into a medical culture that demands more opioids. What was the impact on Americans?
It takes my breath away to say this, but 180,000 Americans have died from using these legal medicines since 2000. More have died from heroin, after having first got hooked on prescription opioids.
One researcher explained to me that once you get hooked, it’s a lifelong trajectory, and you will have to deal with this addiction for the rest of your life. You either get treatment or one day you get a bad hit, you overdose, and you die.
When I was in the Senate and working on the diabetes drug Avandia, before we put out the report that ended up on the front page of the New York Times and on Good Morning America, there was a time when I was not sleeping at night.
It was early 2010, and I knew from internal documents that this drug was causing heart attacks and the company knew it. The FDA knew it. I was having problems sleeping at night, because every hour of every day that I wasn’t working to get this report out, more people were having heart attacks. Did you have some similar problems as you spent months working on this investigation?
Around 2010, the FDA brought in an expert panel to advise them on opioids. The panel said, “You need to mandate opioid training for doctors and do more about these drugs.” But the FDA went against the advice of its own experts and made the training for doctors voluntary.
I spoke to Dr. Nathaniel Katz, who was a former adviser to the FDA. He had traveled from Boston to Washington, as a private citizen, with his own money, to beg the FDA to do more. We quoted him saying, “The FDA failed to make a decision that could have averted many of the thousands of deaths we’re seeing per year,”
After having that conversation, I hung up the phone and it hit me that the FDA had a chance to take the advice of their own experts and save thousands of lives, and they just wouldn’t do it. I had been working on the story around six months at this point. I didn’t break down and cry, but I almost wanted to, because it all felt so futile.
These people with so much power and expertise just couldn’t make the tough decisions.
What do you think causes that? When I was on the Hill, my job wasn’t just to expose but to try and fix problems. I remember one time when the NIH finally got the message that they were funding doctors who were likely corrupt. They admitted this to us in meetings. They knew they had a problem, but they didn’t do anything about it.
I had a conversation with my boss afterwards, who was the Committee’s Chief of Investigations, and she was really mad, almost coming out of her chair, asking me, “What do you when you tell someone they have a problem. They admit, ‘Yes, we have a problem.’ And then they don’t do anything to fix it?! What is your next move? We all admit there’s a problem, but nothing happens to fix it?!”
Yes.
To this day. I don’t have a response to that. What do we do as a society?
You probably care more about the opinion of your neighbor, your friends, and your co-workers than people living on the other side of Earth. In the same way, the life of a senior official at the FDA involves a lot of talking to drug companies. Unfortunately, that’s kind of what the job is. It is a public health agency, but it’s also a gatekeeper for businesses. So all day, your job is interacting with drug company executives or doctors and researchers who are likely paid by drug companies.
In one story, we quote Janet Woodcock, a senior official in charge of drug approvals about why the FDA wouldn’t require doctors to take a class on opioids and safe prescribing. She said, “You can’t imagine the bitter screeds we hear from the prescribing community about the paperwork involved.”
Basically, she was more concerned about doctors complaining about the paperwork involved in some extra training instead of the advice of her agency’s own expert panel.
How has this series altered your understanding of the drug industry and medicine in general?
We only know what is happening to our country and our government, in many cases, after it’s already happened to us. It’s almost a secret history that we unearthed—how the federal government was spun.
It makes me appreciate the importance of investigative journalism. But it’s also sobering. You only know as much as the information you can get your hands on. We only find the tip of the iceberg, in many cases, I’m afraid. In so many cases, you never get to know who was in the room when decisions were being made.
Thanks to you, we can now see what the money doctors are taking. But still, somebody has to come along and read the Open Payments website to put together those relationships.
It’s funny you bring up the Physician Payments Sunshine Act and Open Payments. That’s why I worked so many hours to get that passed, so that we could get stories out like this. How has your opinion changed about physicians? That most august of august professions.
It’s like any profession. You can use that degree to do incredibly helpful things for people and society, or you can use it for pure monetary enrichment. In medicine, if you choose the monetary path, there are so many pharmaceutical companies waiting to help you cash that check.
With Open Payments, I can log on and see this. I think it’s thrown a wrench into the game played by the drug makers. I guess it comes down to shame. If you don’t mind a federal website that lists you receiving thousands of dollars for giving speeches for pharmaceutical companies, then you can do that.
Was there blowback for this series?
I was certain the day this story went out, we were going to get calls from lawyers representing companies or doctors. The first story went out on a Sunday, and I came into the office and sat by the phone the entire day, waiting.
They never challenged a single thing. Every single point in the stories—every medical study cited—was footnoted and fact checked. It pays to do your homework.