New York Times Shows How McKinsey “Guided” Major Opioid Players, Causing Even More Deaths

The New York Times has just published an important new article that shows that McKinsey’s conduct in the opioids crisis was even more deadly than widely realized, by virtue of the giant consulting firm advising opioids merchants beyond just the notorious Purdue Pharma. And as with Purdue, McKinsey strategies to navigate around regulations and boost sales generated more fatalities.

McKinsey Guided Companies at the Center of the Opioid Crisis, by Chris Hamby and Michael Forsythe, draws on over 100,000 McKinsey documents provided as part of its nearly $600 million settlement with state attorneys general.

Let’s turn to an early 2021 post for background:

My most cold-blooded interlocutors, the sort that react to news of corporate misdeeds with a “Gambling in Casablanca?” shrug, are seething over the fact that no one at McKinsey was indicted over its role in stoking opioid sales in the US, nor was the firm charged either. And it isn’t due to class loyalties; they all have advanced degrees and are either in the 1% or the top half of the 10%.

For those of you who managed to miss this story, which was the lead item at the Wall Street Journal when it broke, McKinsey agreed to pay $573 million to settle claims with 47 states and the District of Columbia related to the recommendations it provided to Purdue Pharma and other drug companies for their opioid businesses, with no admission of wrongdoing. Most of the money is to be paid in the next 60 days.

The Journal gave some examples of McKinsey’s advice:

Memos McKinsey sent Purdue executives in 2013 that have been made public in bankruptcy court filings included recommendations that the company’s sales team target health care providers it knew wrote the highest volumes of OxyContin prescriptions and shift away from lower-volume prescribers. McKinsey’s work became a Purdue initiative called “Evolve to Excellence,” which the U.S. Justice Department described in papers released last year in connection with a plea agreement with Purdue as an aggressive OxyContin marketing and sales campaign.

According to bankruptcy court records, McKinsey sent recommendations to Purdue in 2013 that consultants said would boost its annual sales by more than $100 million. McKinsey recommended ways Purdue could better target what it described as “higher value” prescribers and take other steps to “Turbocharge Purdue’s Sales Engine.”

Not to put too fine a point on it, but other disclosures about Purdue Pharma showed that the company set out to create addicts. One approach was that it encouraged doctors to switch from a version of OxyContin that lasted 8 hours to a supposed 24 hour version. But the 24 hour version actually provided only 12, at best 14, hours of relief and Purdue Pharma knew that. When patients came back to their doctors complaining that they were in pain, rather than tell them to go back to the 8 hour formulation, Purdue instead told MDs to increase the dose, when that would clearly not solve the problem.

It’s inconceivable given how much McKinsey probes what its clients are currently doing that the firm somehow missed that Purdue’s sales practices were bound to kill patients. In other words, McKinsey was setting out to “turbocharge” clearly criminal practices.

Now to the New York Times showing how McKinsey’s tentacles reached much further into the opioid industry that was previously recognized, with the firm advising Endo, the maker of Opana, Mallinckrodt, the biggest producer of generic opioids, and Johnson & Johnson, which supplied poppy extracts used to make some of the top selling-opioids. McKinsey also traded on its knowledge of and reputation with the FDA to help these firms game the agency’s procedures to tackle opioid abuses.

And if that isn’t already too cute, in 2017 Tom Latkovic, a McKinsey partner in the health care practice but not part of the pharma effort, launched an initiative “focused on opioids and insights”. One priority was to help state and local governments combat the opioid epidemic. But as the Times pointed out:

…on at least two occasions, the documents show, drafts of publications prepared by Mr. Latkovic’s team were given to consultants for pharmaceutical clients to review. The purpose, a manager in the pharmaceutical practice wrote, was to assess “whether this could create any waves on social media or from journalists that could be harmful to our Pharma clients.”

This article is a case study in the banality of evil. It’s clear that McKinsey has no concerns about the human costs of its advice.

One extended vignette is on Opana:

Purdue was seeking approval from the Food and Drug Administration for a new version of OxyContin that would be more difficult to snort or inject. After the F.D.A. denied its application in 2008, Purdue enlisted McKinsey’s help. The consultants interviewed a former drug dealer about OxyContin abuse, oversaw scientific studies, prepared regulatory documents and coached company officials on how to deal with the F.D.A., which had been a McKinsey client. The agency gave its approval in 2010, and later allowed Purdue to claim the new pills were resistant to abuse.

Soon, OxyContin sales declined — while Opana sales rose. In an internal document, Endo attributed the uptick in part to “patient dissatisfaction with new OxyContin formulation.” Data on abuse showed similar trends: a decline for OxyContin and a rise for Opana.

Endo later developed a new version of Opana it wanted to promote as abuse-resistant. The F.D.A. found that the new pills “demonstrated a minimal improvement in resistance to tampering by crushing,” and that they were “readily abusable” by injection. The agency allowed the drug to enter the market in early 2012, but without being labeled as resistant to abuse.

…the new version of Opana drove many users to switch from snorting to injecting, considered a riskier form of abuse. The likely cause of the blood disorder [showing up in clusters across the US], researchers determined, was the very substance that Endo had added to make the pills harder to crush. When dissolved and injected, it could trigger rapid red blood cell destruction and organ damage.

Yet as the evidence of the danger of Opana was mounting, Endo hired a new CEO from McKinsey, who with the firm’s help did a tax avoidance deal that enabled Endo to go on an acquisitions binge, which included buying other opioids companies.

Under the new CEO, and again with McKinsey’s help, Endo pushed its dangerous pills harder. And notice how McKinsey is in the drivers’ seat:

In summer 2015, McKinsey helped launch the “Sales Force Blitz,” which the firm said in a statement applied to a range of Endo’s products…

While the company had pulled back its marketing of the painkiller, McKinsey now advised it on how to do the opposite…

A consultant, Sherin Ijaz, expressed her excitement in an email to the head of Endo’s pain business unit, John Harlow. The next step “is to identify the sweet spot of docs so we can do targeting,” she wrote, adding that the “fun” begins “on Monday!”

“Agreed,” Mr. Harlow replied, “and the fun is just beginning!”

When two Endo executives proposed shifting some sales calls to promote the company’s arthritis gel, McKinsey was opposed. Doing so would be a distraction “at a time when we want to drive Opana,” wrote another McKinsey consultant, Nicholas Mills.

Ultimately, the consultants directed Endo to focus on more than 3,000 additional physicians with promotional messages about Opana.

In 2017, less than two years later, the F.D.A. took the rare step of demanding that Endo pull Opana from the market, citing the grave public health consequences of its abuse.

The authors describe how McKinsey had developed sophisticated techniques for targeting doctors, particularly reluctant ones, for Oxycontin, and implied it used similar ones on Opana:

The consultants interviewed dozens of physicians and solicited the views of hundreds more in a survey. Four groups of doctors emerged, each with a distinct profile. The consultants then developed messages to appeal to each group’s practical and emotional needs.

McKinsey identified a particular opportunity in doctors who were hesitant to prescribe OxyContin because of worries about abuse, addiction and possible scrutiny from the D.E.A. These physicians often tried to treat chronic pain with less powerful drugs….

Purdue, dissatisfied with dipping OxyContin sales in 2013, had enlisted McKinsey’s help. Revenues were down, the consultants advised, in large part because of government actions to tamp down the opioid epidemic. Doctors were writing prescriptions for fewer tablets and lower doses, and wholesalers and pharmacies were imposing new controls..

McKinsey called for a shift “to offense”: Purdue needed physicians to start new patients on OxyContin. Drawing on an array of data — more than just a list of high prescribers, which had been the focus of Purdue and other drug companies — the consultants identified specific doctors to target.

McKinsey decided to stop serving opioids players only after the Massachusetts attorney general exposed the firm’s role in a filing against Purdue Pharma.

Two closing thoughts, and I hope readers can help with the first. I wonder how many other countries have their medical industry structured so as to facilitate this type of abuse, of manipulating doctors to prescribe pills so as to increase company profits. One reader, a savvy businesswoman, is horrified that her oncologist son-in-law chose which new job opportunity to take based in part on the magnitude of kickbacks for prescriptions he was to receive.

More generally, doctors, depending on how they are housed, were small businessmen and even when in large health organizations, are still profit centers from the pharma perspective. The fact that drug companies can afford in-person selling to them gives an idea of the profit stakes.

I find it hard to think that this sort of personal selling takes place in Australia, where at least when I was there, the Therapeutic Goods Administration reviews the medical research for drugs, typically picks one in each category, and bargains hard on price. The TGA was particularly good at avoiding minor reformulations designed to greatly increase price and/or extend patent life.

Since doctors in Australia can prescribe only medications that the TGA is buying, that limits physician choice and thus the potential upside of manipulating doctors. Bargaining drug prices down would also lower the drugmaker profits and hence the incentive to engage in personal selling.

I would assume the picture is similar in countries with national drug-buying, such as the NHS, but please pipe up!

The second closing thought is to debunk the notion that I am being unfair to McKinesy in depicting the firm as indifferent to human health. From a November 2021 post, McKinsey, the Force Multiplier for the Opioid Crisis, Goes All in With Anti-Public-Health Messaging on Covid:

It has been deeply disturbing to see how what passes for leadership in advanced economies has consigned its citizens to unnecessary Covid risks, and with that, the very real odds of significant reductions in lifespans, in the name of profit.

Virtually everyone in authority, from supposed medical experts to pols to the press, talks about Covid mortality and morbidity as if it were a one shot game…

As our reader GM keeps stressing, even if one assumes that patients are scrupulous in keeping up with vaccinations, it still translates on average into multiple Covid cases for a young adult by the time he reaches 65, unless we get lucky and eventually get a near or actually sterilizing vaccine down the road. Each Covid infection carries with it morbidity risk, such as lung, kidney and heart damage, fatigue, brain fog, and inflammation. There is no good data on how lasting this sort of damage is. That means that some, potentially many patients will go into their second (and third, and fourth) Covid case in a diminished state as a direct result of prior Covid infection, independent of aging and other co-morbidities like diabetes developing in the meantime….

Campaigns for the commerce-favoring “Let ‘er rip” approach have included stunningly dishonest messaging, like “herd immunity” when coronavirus infection does not produce lasting protection, or “Covid is no worse than the flu” when flu doesn’t do lasting damage to survivors. The new version of this “Get happy with dying younger than you should have” are the new spins of “Learn to live with Covid” and trying to make Covid becoming endemic as not so bad.

A new article by McKinsey, a proud recidivist in moral dereliction, does a public service of sorts by putting many of these rancid arguments in one tidy piece, Pandemic to endemic: How the world can learn to live with COVID-19. After getting two odious meme in the headline, it goes full bore into another in the subhead: “With prospects of herd immunity fading…”

If you have the stomach, GM, KLG, and IM Doc did an impressive job of shredding this rancid McKinsey piece. But unfortunately, McKinsey has a much bigger megaphone than we do, and continues to go from scandal to scandal with its influence intact. Unfortunately, that’s an indicator of accelerating moral and social decay in the West.

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  1. orlbucfan

    Moral decay is not just in the West; it’s in the East, North, and South. We are living in a new Dark Ages, I’m afraid. McKinsley: just another corrupt, craporate joke!

    1. Questa Nota

      McKinsey is happenstance.
      Goldman is coincidence.
      PMC is enemy action.

      Reorder to fit your view.

      There are systemic problems in how US businesses conduct themselves. In other parts of American life, for example the football cheating scandal at SMU, such activities would result in a type of death penalty. Instead, top graduates clamor to work at McKinsey, Goldman and other PMC hives instead of doing something productive with their lives. Gotta pay for that avocado toast, or whatever the sensation du jour is now.

    2. Bawb the Revelator

      If Pete Buttigieg was ambitious enough to learn Norwegian just so he could read Karl Ole Knausgaard’s enormous, tendentious memoir “My Struggle” in the original, what’s the bet that Pete found “Mein Kampf” a snap?

      Using McKinsey and his smarts to shoehorn himself into the POTUS is probably child’s play for Pete. I’m more fascinated than envious of Pete who reminds me of Budd Schulberg’s Sammy Glick in “WHAT MAKES SAMMY RUN?”

  2. Samuel Conner

    In the context of a couple of years of seemingly intentionally bad public health policy, the thought occurs that government extraction of penalty funds, with no prosecutions and no stipulation of corporate guilt, in the wake of corporate profit from activities that reduce the population, … has something of the character of a self-licking ice-cream cone (for as long as the ice cream remains semi-solid and the soggy cone doesn’t collapse). From one side, it’s a cost of doing business; one fears that from the other side, the policies that were non-criminally penalized (perhaps this is functionally an unusually high rate of tax on profits, obtained via alternative means) are not regarded with as much hostility as public statements might imply.

  3. Ignacio

    The doctor by doctor approach is common everywhere but it may depend on what you sell and what speciality you deal with. What is different, may be, is the kind of incentives you can offer them. From a friend of mine, in Spain, in public institutions economic incentives and gifts are strictly forbidden but incentives on offer might be related with career promoting such as promoting assistance to congresses, participation in trials and the like. Those can be helpful to somehow make them more favourable to the interest of the seller. I am just writing what I am recalling from a conversation months ago and don’t feel 100% comfortable with it. Nevertheless my friend told me that to his experience it was not that easy to enlist physicians in Spain. But this is oncology that might be one of the most difficult disciplines to deal with.

  4. Space Station 11

    I’ve observed a dizzying change in messaging regarding pain control in the emergency department during my career. I remember early in my training being scolded for not aggressively treating pain; pain scales as the ‘fifth vital sign’; enforcement of JCAHO pain control standards, etc. And only a few years later being introduced to DEA prescription monitoring systems so we could track each patient’s history of controlled substance use. In other words “You guys stink at treating acute pain! And here’s a tool to monitor how many addicts you create!” At least that’s how it felt to me at the time.

    I guess you could say I now fall into the category of ‘ER Delayers’.

  5. Michael C.

    Though since the political class embraces corporate money allowing them to retain power, in a world built on the social wellbeing of people rather than profit the government could revoke the charters of companies that engage in this type criminality. But that would require a government that controlled the nation rather than a nation controlled by rapacious capitalists. Unfortunately, I don’t see it happening anytime soon.

  6. John Emerson

    I have known several people with chronic or acute pain who have spent long periods of misery, in the chronic cases over and over again, for fear that either they weer either addicts scamming drugs, or that they might become addicts. This problem is often treated as a matter of greed, careless or venal doctors, and addiction, but another aspect of the problem is that people who need pain relief are not getting it.

    The decisions seem to be made by committees of lawyers, insurance reps, hospital admins, and PR reps, with MDs only occasionally involved.It seems now to be impossible to me that either the addiction problem will be brought under control, or that people who need pain relief will be able to expect to get it.

    But I’m a doomsayer.

  7. thelonegunman

    a huge root in the causal analysis is the >20 year history of the USDD and VA proscribing Oxy for PTSD for all the folks touring through Iraq, Afghanistan, Syria…

  8. Dave in Austin

    To depressing for words. There are only two solutions I can think of.

    First, make us part of Canada with no right to vote for five years.

    Second, eliminate healthcare for all government employees, including everyone who gets a salary including the members of Congress and the Courts, then bump their salaries a bit and let them deal with the free market. Exempt sitting Presidents. Exempt the military because they might stage a coup.

    I think either solution could easily be implemented shortly after Donald Trump is finally elected Pope Donald the First.

  9. Barry

    In Australia the TGA (Therapeutic Goods Administration) is the regulator. What it does –

    The Pharmaceutical Benefits Advisory Committee (PBAC) is an independent statutory body which makes recommendations and gives advice to the Minister about which drugs and medicinal preparations should be subsidised on the PBS. Its next meeting agenda

    The Pharmaceutical Benefits Scheme (PBS) is an Australian Government program that subsidises medicines Costs -From 1 January 2022, up to $42.50 for most PBS medicines or $6.80 if you have a concession card. The Australian Government pays the remaining cost.

    Annual Safety Net on pharmaceuticals.On 1 July 2022, the Safety Net threshold is to be $244.80 for concession card holders and $1,457.10 for all other patients. The safety net applies to a family unit.

    Australia has had problems with opioid use
    This report from 11/2018 with comparisons with Canada
    The full report can be downloaded from there

  10. Bawb the Revelator

    If Pete Buttigieg was ambitious enough to learn Norwegian just so he could read Karl Ole Knausgaard’s enormous, tendentious memoir “My Struggle” in the original, what’s the bet that Pete found “Mein Kampf” a snap?

    Using McKinsey and his smarts to shoehorn himself into the POTUS is probably child’s play for Pete. I’m more fascinated by than envious of Pete who reminds me of Budd Schulberg’s Sammy Glick in “WHAT MAKES SAMMY RUN?”

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