The Opioid Epidemic As A Crisis Of System, Not Individuals

Like a lot of people I was gripped by this New Yorker story about the Purdue Pharma company and its role in creating and perpetuating the opioid epidemic. And, presumably like a lot of people, I was appalled by various aspects of the story -- like massive efforts to hide the addictive nature of the drug even in the face of massive harm.

But as I read along, I was also a bit weirded out by the focus on the individual family members who run Purdue Pharma. One reason this weirded me out is that a lot of the story seemed to involve examples of people doing everything they can to defend and preserve their company and their product. But isn't the way capitalism works in our society predicated on the idea that this is what people do?

We've known forever that if you create a system in which some of the methods you can use to get ahead will be collectively destructive, people will be incentivized to use those methods. And I would say recent history supports the idea that if you want that not to happen, you can't rely just on some vague notion like individual responsibility. You need systems in place.

That's why we have things like the FDA, and policies about conflicts of interest, and so on. Why wasn't more of this story about that?

The article describes various kinds of factors leading to the crisis. Sales reps were trained in "overcoming objections" from clinicians, sometimes with exaggerated or false information, where doctors were vulnerable because of "wishful thinking" -- they wanted a pill that would help their patients.  Purdue paid clinicians to attend medical conferences and give presentations about the merits of the drug -- in places like Boca Raton. The marketing thus involved a deadly circularity: "the company convinced doctors of the drug’s safety with literature that had been produced by doctors who were paid, or funded, by the company." They "duped" the FDA into thinking the drug lasted 12 hours and wasn't addictive. They created a concept of "pseudo-addiction," which they said explained addiction-like symptoms in terms of under-treatment  of pain.

Yes -- there is a lot of bad behavior here. But what was supposed to prevent this from happening? Modern capitalism is a cut-throat business. In a society where American Airlines can be criticized for raising pay for pilots and flight attendants, there are huge incentives in place to do whatever's necessary to make your product sell. If other people are behaving badly, you may have to behave badly too, just to stay in business.

I had always thought that this is why we have rules and systems in place. Isn't the FDA supposed to work on principles that make it extra difficult for an individual company to "dupe" it? Didn't there used to be stronger rules about conflicts-of-interest? This is one reason in the past that advertising wasn't allows for drugs -- as the article says, "advertising has always entailed some degree of persuasive license." What happened to that idea?

The company -- and the family who run it -- have been sued in court, but have settled, often for sums said to be small compared to the cost of righting the wrongs in question. In some cases, they have been ordered to pay fines, but again, the amounts won't make a dent in their profits. The article quotes Arlen Specter, the Republican senator from Pennsylvania, remarking that such fines amounted to "expensive licenses for criminal misconduct."

These all reflect problems with the system. Regular readers may remember a previous post on this issue discussing Sam Quinones's excellent book Dreamland. One thing that Quinones says is how often the people mitigating disaster and finding solutions come from some kind of governmental or collective institution or agency: they are in the court system, or the health care system, or whatever. Yes, there are people doing bad things and good things but everyone is ultimately caught up in a web of conflicting societal needs and pressures. This is a very different -- and I think more enlightening -- perspective.

The article lambasts the individual family members who run Purdue Pharma, asking how they can possibly live with themselves. I get that. But so many of us are complicit in some kind of awfulness -- buying gadgets with conflict minerals, depositing carbon into the air for holidays, enjoying the fruits of energy from companies engaging in global exploitation. In our society, complicity in harm is not restricted to a few bad actors.

As we've said before in this space, blaming corporate "greed" is often naive and misplaced, because in our corporate world, if you're not as cut-throat as the next guy, you're going to fail. It's not an "individual responsibility" sort of thing. It's a system thing. Sometimes, the framing of individual actors as good or bad loses some of its usefulness. Modern capitalism may be one of those times.