Academy award-winning director Alex Gibney typically dedicates years of effort and research to producing his powerful and often shocking documentaries about corporate greed and government corruption. His new two-part HBO series on how Big Pharma greed begat the casualties of the opioid epidemic, "The Crime of the Century," is no exception.
The son of a journalist father, Gibney said he took lessons from how he saw his father become dispensable, a cog in large media organizations who was disposed of too soon – despite his hard work and intense curiosity. "He worked for a lot of big mainstream media outlets, print, like Time and Newsweek, and was fired from most of them," Gibney said on "Salon Talks." "He sucked down and kicked up, which didn't end up being a good career path for longevity, but at the same time, it did teach me two things: an emotional resistance to authority . . . and what I got most from him was that rapacious sense of curiosity – keep digging, find out what's really going on."
For "The Crime of the Century," dig Gibney did. Much of his time was devoted to going through reams of data and corporate emails related to Purdue Pharma, in partnership with Washington Post reporters, following up on stories about the pharmaceutical industry's intentional calculation of creating drug dependence in specific populations for profit. Supporting stories in the film come from in depth interviews with former employees, drug enforcement officials, and recovering opioid addicts themselves.
"A lot of people behaved terribly in this story, some of whom self-confess," he said of his biggest takeaway from the work. "But I think the bigger problem here is a systemic problem," Gibney said.
"Our incentives are all wrong, and they are geared towards making money, rather than making people better. That's what I came away with, and was the 'a-ha moment' for me. Not only did I realize that the crisis was something that was manufactured as a kind of a crime, but it was manufactured for profit over people."
You can watch my "Salon Talks" episode with Gibney here or read a Q&A of our conversation below.
The following conversation has been lightly edited for length and clarity.
What made you want to dig deeper into the opioid crisis in particular and to do so differently when so much has been reported on it?
In having a conversation with a number of editors and reporters at The Washington Post, it became clear to me that the part of the story that was missing was the broad sense that this wasn't something that just happened. It wasn't like a cyclone or a hurricane or even a pandemic, a disease that was beyond our control. This was something that was manufactured by human beings and companies.
And also that it was a great crime. If you put the elements together, it was not just a crisis. It was a series of crimes. And that to me, gave me a reason to do it, that you could put together these details in a way and paint the big picture that was really missing from the sense of the opioid crisis because a lot of us hammering about it, it's like, "Oh, isn't it terrible? Surely there isn't anything we can do." Well, there is something we could do. We could hold those who committed the crimes accountable and also change the system that allowed the crimes to be committed. With that, I set off in motion, again with a theory but needing to report it out and to figure out whether or not I was right.
Let's talk a little bit about the drugs that are featured in the film. From my watching of the film, these are essentially heroin pills. It was intentionally marketed to chronic pain suffers and not surgical patients. This ideology was actively promoted by the Big Pharma manufacturers. In the film, the idea that the coding on the pills has a delayed absorption is called a historic mistake by one of your subjects. Can you speak to that?
Sure. The drug that you're talking about really is OxyContin. That's the famous drug manufactured by Purdue Pharma, which has been owned for many years by the Sackler family and they become rather infamous. OxyContin is kind of a combo term that combines oxycodone, which is a narcotic that comes from opium which is two times as strong as morphine with a content system, which is a time-release system. That's what was the inventiveness.
They had something called MS-Contin before, which was a time-release system for morphine. Then when the patent for that was running out, they came up with OxyContin where you had a numb, more powerful narcotic, but you were still going to use this time-released. And they believed, and I say, belief is an important thing because it ends up being actually in the package insert that the FDA allows them to use, but they believe that this time-released system would do two things. One, it would make it non-addictive and two, it would make it resistant to abuse.
I think they knew better. Let's just put it that way, they knew better because they knew based on the data that they were getting from MS-Contin, that people were abusing MS-Contin widely. And they did their own studies which showed that you could abuse these drugs. On the package it says, "do not crush" or I can't remember the exact phrase, but it's like, "do not crush, do not snort" etc. and it's basically an instruction manual for how to abuse these drugs. Instead of just eating it as you're supposed to, you crush it and you snort it or you put it in a spoon and mix it with water and you inject it. And people seeking a very powerful high discovered this very quickly.
And the Purdue executives knew all about it. We have emails that show that they knew. And yet when reports of abuse coming out of Maine and Western Virginia started to surface in 2000, the Purdue executives were all like, "Oh, I'm shocked. There's abuse? Who knows?" And this is one of the original sins. They actually start working, they meaning Purdue, they started working with a guy named Curtis Wright, who is a medical officer at FDA. And he was supposed to review their drug. Well, they work with him to effectively write the review of their own drug.
And in that review, it says, "it's believed" again, back to that word, belief, it's believed that this is effective, I can't remember the exact phrasing, but that this content system will prevent abuse. And that's just not true. It was easily foiled and they knew it and they also knew the damage that was being done. And they kept promoting this idea that you couldn't get addicted and it was not subject to abuse and neither of these things were true.
In the film, and you just mentioned, you made a reference to West Virginia, to Maine, some of the communities across America that have been hit the hardest by this epidemic. Poor and hardworking manufacturing communities in rural areas have higher numbers of addicts and the fact that those areas have had those numbers is not an accident. Can you explain?
I mean, it's not an accident in the sense that there is a great sense of despair in communities like that. And so people are prone to use these drugs as a result of that kind of economic despair. I think the other issue is that what ended up happening was when you start, after a while you need higher and higher doses to get the pain medication. You learn that you can't really afford it and you end up going elsewhere, sometimes to heroin, and then ultimately to Fentanyl. And not just because of the pain, but also because you're addicted now.
And I think that's the one thing that was so terrifying in this epidemic was that, look at in economic terms, what OxyContin did was to create a new demand. We all talk about supply and demand. They had the supply and they created the new demand for opioids, which then had to be met either through OxyContin or later through heroin and Fentanyl. A lot of times companies like Purdue and others say, "Well, we don't have anything to do with Fentanyl. That wasn't our drug." No, what Purdue did do was to get people addicted to opioids, and then they sought out alternatives that were more affordable.
In your research, working with The Washington Post reporters in the story, were you able to find reports of large trials showing percentages of people who do get addicted to opioids versus the number of prescribed?
There were a number of studies that show that 8 to 12% of people using an opioid for chronic pain develop an opioid use disorder and close to 30% of patients misuse them. Ultimately you have an incentive by the manufacturers and the distributors and the distributors are some of America's largest corporations, companies like McKesson, AmerisourceBergen and Cardinal Health to sell as many of these drugs as possible. And that's what you want to do, right? Do you want to make as much money as possible to deliver a return to your shareholders?
They have a tremendous amount of data about where these pills are going. Every pharmacy in every county in America. Once you have access to that information, you realize that in a small town in Western Virginia, they're sending enough opioids to literally supply an opioid a day for every man, woman and child in that county. You know, it's not just for back pain, you know that something's going on, that these pills are being diverted.
You're on the lookout for doctors who are either imbued with the belief that no dose is too high, that we're under-medicating pain and so they're going to sign up, or dirty doctors, doctors who are going to sell massive amounts because they're making money. The motive of selling as many drugs as possible ends up encouraging a system of abuse.
When you talk about addiction to any kind of substances that the makers of these drugs, whether it's Fentanyl, Subsys, Oxy, assert that the addict is the problem, not the drug and that these people are not victims of a huge corporate effort and the drug's availability. What would you say to people who say that?
It's just wrong in the face. The idea that there were two different kinds of people: there are addicts, and then there's the rest of us who aren't addicts. It flies in the face of what we understand about the nature of opioids. And one of the things we do in the film is to begin Part 1 with a condensed history of opioids, going all the way back to King Tut, to show that we have a long record of understanding just how addictive these drugs are. It shouldn't be a mystery to us in the 21st century. There's a danger of addiction with these drugs just as there was a danger of addiction with cigarettes. Not everybody becomes hopelessly addicted, but many people do. And there was certainly a danger of it.
The problem comes if you're the manufacturer or you were the distributor when you pretend that there is no danger and you try to make believe that they're perfectly safe. "You could take as many as you want. And if you stop using them, there's no withdrawal symptoms." It's really intensely irresponsible. And that's what leads to these problems. One of the things that Purdue did, which was then used as a kind of a model by other companies, was the focus on the doctor. And to basically pull the doctor into this world of needing, to treat pain with opioids and higher and higher doses of opioids. And the way they would do that is through a series of speaker programs. And over time, that has a kind of psychological impact. It's a variation of what I call the MRI theory.
In other words, if you're a doctor's practice and you buy five MRI machines, right? Lo and behold, it's likely that your prescriptions for MRIs are going to rise. Not because you're a bad person, but because you now have an economic incentive to serve those MRI machines that you've already bought. Well, doctors are being paid to proselytize about OxyContin and lo and behold, they're probably not as assiduous about seeking out the problems of OxyContin abuse or OxyContin addiction as they would be if they weren't getting paid. That ends up being the commercial mechanism by which a huge medical crisis has cost.
There's this sort of tremendous amount of persuasion that goes on and the power that these pharmaceutical companies wield became so amazing to me. And this has been allowed in America through classism and racism for as long as there have been drugs to test. And it's almost always on poor or uneducated populations or those of color or both. How do we as a country change this horrible pattern of abuse?
Well, I think one thing that we can do, particularly when it comes to healthcare is to change the system. I mean, honestly the system is broken and the system is broken because it's so full of bad economic incentives that reward profit takers and put at risk human beings and human lives. And that really is the sum of it. And obviously we can do a better job of educating people. And obviously we can do a much better job of rooting out systemic racism and income inequality. There's a lot of problems to deal with but I think when it comes to healthcare, we've allowed a kind of crazy quilt system of colliding profit centers to distort what should be a simple relationship between patient and doctor. And that I think is a problem we should fix.
One of the reasons I wanted to make this film was because it really highlights how flawed our healthcare system is and I think that's something that came up during the pandemic as well. In a pandemic, if you're not caring for the poorest among us, then actually everyone ultimately is put at risk because everyone is contagious. The problem then becomes a systemic one that we've allowed profit takers, kind of turbo-charged 21st century capitalism to take over what should be a system of healthcare rather than return to investors.
What do you say to people, whether they're doctors or not who are like, "But I need this or I can't function," after making this film? Is there a more measured approach to prescribing opioids on their horizon rather than getting rid of them altogether?
Yeah. I would not argue for getting rid of them altogether. I mean, a drug like oxycodone, not in its time release formula, but pure oxycodone can be a very valuable drug post-surgery for example, for three or four days. You're not going to get addicted and it's great for the relief of pain. We know that a drug like OxyContin can also be terribly valuable for end of life cancer pain.
And there are other patients for whom long-term OxyContin may be advisable but it was the marketing push. And by the way, those patients can still receive OxyContin. It's not like it's been made illegal but what happened here was a business maneuver to make people believe something that wasn't true, which is that oxycodone and OxyContin is not addictive. That's not true. And also to believe that no dose is too high. That's just not true. And also to prescribe far more widely than is warranted, given the danger of these drugs. Those were all marketing tools that were used not to look out for the best health outcomes for the patient, but for the best return on investment for the corporation and that's the problem.
What was the most important thing you learned from making this series and what is it that you'd like people to walk away with?
The most important thing that I learned was, you look at incentives in a story like this and it's easy to say, "Okay, there's white hats and there's black hats." And a lot of people behave terribly in this story. And we show many of them, some of them self-confessed, but I think the bigger problem here is a systemic problem. Our incentives are all wrong and they're geared toward making money rather than making people better. That's what I came away with.
And that's the thing that was kind of the a-ha moment for me. I mean, not only did I realize that the crisis was something that was manufactured as a kind of a crime, but it was manufactured for profit over people. And that was really the scariest thing for me to understand. And for everybody out there who watches this I'll hope they'll agree that while we need to fix the opioid crisis, a bigger issue ahead for us is fixing our healthcare system in a way that the incentives are aligned with the well-being of citizens rather than the profit of corporations.
"The Crime of the Century" premieres Tuesday, May 10 at 9 p.m. on HBO and HBO Max.