Where to begin in writing about the opioid epidemic, and Alex Gibney’s excellent documentary on the subject, The Crime of the Century? Like most Americans, this epidemic has a personal side, from the extended family member drugged into stupefaction by careless doctors, to former classmates with children dead from overdoses.
As a physician, I’ve been on the professional side of it, too. When I worked in Tennessee (a major stopping point on the “OxyContin Highway” described in the film), I knew of four local pill mills shut down by the DEA. When in private practice, many, many doctor shoppers came through my doors, including one whose concerned wife took me aside to discuss their drives to Florida to score narcotic prescriptions. I’ve seen countless individuals – youth, parents, grandparents – pass through the revolving doors of detox, rehab, and prison, in a system that prioritizes punishment over treatment.
Even as a callow resident-in-training, the pernicious presence of Big Pharma registered on my mind: it starts with cheap pens and cheese danishes but progresses to lavish meals whose price of admission is listening to a speaker spout out drug company talking points. As a young physician, I was already aware of the data showing the influence of sales reps on prescribing practices, despite my colleagues’ certainty that they were impervious, thanks to their cynicism and superior critical thinking. In my lone trip to the American Psychiatric Association’s annual meeting, it appalled me to walk past the shamelessly massive Big Pharma expo. Each morning, as one of the comparably few entering to hear unsponsored lectures, I was walking against the tide of people exiting the hall after their free drug company breakfasts.
Nonetheless, it is still enlightening and sobering to have the opioid epidemic – and Big Pharma’s culpability in it – laid out so clearly and expertly. The Crime of the Century is a tough film to watch, as Gibney returns repeatedly to footage of EMTs arriving on the scenes of overdoses, to rightly put faces on some of the half-million who have died in America since 2000. We meet a dad whose college-aged daughter overdosed on Fentanyl, a family practitioner in rural Appalachia where 25% of the local 11th graders have taken illicit opiates, and a Salt Lake City husband whose wife was killed by the obscene volume of painkillers and sedatives doled out by her pain doc. (Remarkably, this physician went on camera with Gibney, one of many perpetrators whose appearance here illustrates the truism that no-one is a villain in their own mind. The excuse-making, narcissism, and victim-blaming on display across this film is staggering.)
For a two-part documentary that runs nearly four hours, very little if anything feels superfluous in The Crime of the Century. In chronological fashion, Part One dates the beginning of the epidemic to the release of OxyContin in 1996, by Purdue Pharma as headed by the now-infamous Sackler family. In the first of many instances that screams “conflict of interest,” FDA leader Curtis Wright helped Purdue write OxyContin’s application, which he then approved. (He later went to work for them, scoring a hefty salary.)
With the aid of journalists from The Washington Post, ProPublica, and The New Yorker, Gibney’s film demonstrates that the Sacklers and their co-conspirators in the Purdue cartel knowingly minimized the risks of getting hooked on OxyContin, as their salesforce pressed physicians to prescribe ever higher doses. A Purdue rep in Florida even recruited a patient from a doctor’s office to be a poster child for limitless dosing. A former heroin addict with superhuman tolerance, this gentleman at one point was taking 25 160 mg tablets twice daily, whereas a single tablet would likely send an opiate-naïve person like me into respiratory arrest. Drug salespeople were offered uncapped bonuses based on prescribing habits in their region, with salaries upwards of $300K yearly.
Part One of Gibney’s doc concludes with district attorneys in Appalachia putting together compelling cases for criminality against Purdue. Politicians of both parties – from Connecticut’s Chris Dodd to dear old Rudy Giuliani – rush to the Sacklers’ defense, and the Department of Justice either declines to prosecute or issues meaningless penalties.
Part Two resumes the story with pill mills and the rise of Fentanyl. Learning from the Sacklers that killing Americans for profit goes unpunished, less scrupulous operators rise up to claim corners for their dealers. John Kapoor starts Insys, creator of Fentanyl in spray and lollipop form. Kapoor’s sales force loves their uncapped bonuses more than Purdue’s, offering sex and cash bribes (often through their “speakers’ program”) to their most prolific prescribers.
The second part broadens its focus to include other profiteers from the opioid trade, namely the big three drug distributors (Cardinal Health, AmerisourceBergen, and McKessen) and the pharmacies to which they send medications (addicts and their docs loved the neglectful dispensing by CVS in particular). Here, the DEA also comes into the picture, as their diversion interdiction department looks for suspicious peaks in activity not only in doctors’ practices but at these levels, too.
In the 2010s, the DEA attempted to go after the big three distributors, since they repeatedly failed in their legal obligation to intervene in the face of suspicious overprescribing. This leads to yet another failure of governance, as Big Pharma lobbyists press for intervention by Tennessee Senator Marsha Blackburn and Pennsylvania Representative Tom Marino (later a Trump nominee for Drug Czar). Lobbyists fed Blackburn and Marino questions for their public grilling of DEA leaders, and later did the ghostwriting of legislation they co-authored to cripple the DEA’s efforts.
As someone who always votes Democrat, I wish I could say Big Pharma infiltration into politics has solely been a Republican problem. And Big Pharma has certainly been generous in filling the campaign coffers of folks like Blackburn, Marco Rubio, and Kevin McCarthy. But Obama signed Blackburn and Marino’s legislation without hesitation, and it was a former Deputy Attorney General under Clinton, now working in the private sector, who helped Purdue dodge DOJ intervention.
All told, The Crime of the Century provides plenty of fuel for righteous anger against the conflicts of interest that poison governance, as well as the noxious presence of lobbyists in D.C. Clearly, President Biden and the Democratic Congress need to act against them while they can. (Biden, with a son who has very publicly struggled with addiction, surely would want to act out of enlightened self-interest if nothing else.)
In addition to educating us on political sausage-making, I hope Gibney’s film will result in greater compassion for families battling addiction. As a physician, I suspect the engaging storytelling here will lead other colleagues besides me to look more closely at our prescribing habits, in a way that our annually-mandated, dry-as-dust educational modules simply can’t. And it would please me beyond measure if The Crime of the Century led more prescribers to swear off Big Pharma dinners and industry-sponsored misinformation sessions.
(The Crime of the Century starts playing on HBO Max on May 10th.)
(Image credit for star rating: Yasir72.multan CC BY-SA 3.0 )