Purdue Pharma taps a Gilded Age history of pharmaceutical fraud

Newly unsealed documents from a lawsuit by the state of Massachusetts allege that Purdue Pharma, maker of OxyContin and other addictive opioids, actively sniffed out new, sinister ways to cash in on the opioid crisis.

Despite years of negative press coverage, unwanted attention from regulators, multi-million dollar fines and several major lawsuits, Purdue staff and owners sought to expand the company’s sights beyond its usual array of opioid painkillers. Purdue planned to become an “end-to-end pain provider,” by branching into the market for opioid addiction and overdose medicines, looking to peddle these medicines even while the company continued to aggressively market its addictive opioids. Internal research materials coldly explained the rationale behind this plan: “Pain treatment and addiction are naturally linked.”

As thousands of Americans continue to overdose on opioids annually, Purdue’s secret marketing research predicted that sales of naloxone, the overdose reversal drug, and buprenorphine, a medicine used to treat opioid addiction, would increase exponentially. Addiction to Purdue’s opioids would thus drive the sale of the company’s opioid addiction and overdose medicines. Purdue even planned to target as customers patients already taking the company’s opioids and doctors who prescribed opioids excessively, according to the Massachusetts lawsuit filing. To keep the plan quiet, Purdue staff dubbed the scheme “Project Tango.”

According to the Massachusetts lawsuit, Purdue used this graphic in its internal strategy materials to illustrate Project Tango. State of Massachusetts, CC BY-SA
The audacity of Project Tango enraged many observers. But considered in historical context, the news that Purdue sought to peddle opioid addiction medicines while continuing to sell opioids seems less surprising. In fact, there is clear historical precedent for Purdue’s business plan. Over a century ago, “patent medicine” sellers pioneered this strategy during the U.S.’s Gilded Age opiate addiction epidemic.

Opiate addiction in the Gilded Age

Opiates were some of the most commonly prescribed medicines in American history until the 20th century. Pills containing opium, hypodermic morphine injections and laudanum, a drinkable liquid concoction of opium and alcohol, constituted half or more of all medicines prescribed in American hospitals during most of the 19th century, according to research by the historian John Harley Warner. Opiates were also present in countless “patent medicines,” over-the-counter panaceas made of secret ingredients, often sold under catchy brand names like Mrs. Winslow’s Soothing Syrup. Americans could choose from 5,000 brands of patent medicines marketed for all manner of ailments by the 1880s. In 1904, just before federal oversight began, patent medicines had matured into an astonishingly profitable industry, with estimated sales at US$74 million dollars annually – equivalent to about $2.1 billion dollars today.

Opiate-laced prescriptions and patent medicines often caused addiction. The historian David T. Courtwright estimates that opiate addiction rates in the U.S. skyrocketed to 4.59 per thousand Americans by the 1890s – a high rate, although lower than the rate of fatal opioid overdoses in recent years. Most individuals developed addictions through medicines, rather than the infamous smoking variety of opium. Victims of “the habit” cut across demographic lines, encompassing middle-class housewives suffering from menstrual pain, Civil War veterans reeling from amputations and many others in between.

Yet even for those who became addicted to prescription opiates, the condition was socially stigmatized and physically dangerous. Like today, addiction to opiates often led to fatal overdose, condemnation and sometimes even involuntary commitment to mental asylums. As one doctor reported to the Iowa Board of Health in 1885, addicted people lived “truly in a veritable hell.”

To avoid these frightful outcomes, desperate, opiate-addicted Americans frequently sought out medical treatment for their condition.

Gilded Age Americans could choose from a range of therapies for opiate addiction. Wealthy patients frequented plush private clinics, where they could receive inpatient treatment for opiate addiction. The most popular were the Keeley Institutes, which offered patients injections of the “Bichloride of Gold” remedy, invented by the doctor Leslie Keeley.

Scores of Keeley Institutes sprang up around the country in the late 19th century, a testament to the popularity of Keeley’s “Gold Cure,” which he marketed for alcoholism and drug addiction. No up-and-coming Gilded Age city was complete without a Keeley Institute. At the height of the Gold Cure craze, there were 118 institutes serving 500,000 Americans between 1880 and 1920. Even the federal government had a contract with Keeley to provide the Gold Cure to addicted veterans. Although injections of the Gold Cure had little intrinsic medical value, historians believe that socializing with other like-minded patients in the Keeley Institutes may have helped some patients recover from addiction.