a pill in place of a model globe

When it comes to opioids, it’s all about turf.

By Stephen Wood

When it comes to selling opioids, turf matters. Access to customers and geography play a role in the day to day sales of opioids. This often means selling in areas where there is a wanting and willing customer base with funds to spare. It also means picking a spot, a corner, where enforcement is low or where corruption can overcome most legal problems. The delivery can’t be too conspicuous. It needs to be hidden from plain sight, done in the shadows or alleyways where no one is looking. It’s a craft and when done right can lead to fistfuls of cash in the hands of the distributor, the dealer.

This may sound like a street-level drug deal, but it isn’t. It’s the tactic many American pharmaceutical companies are taking in response to increased regulation on prescription opioids. Like the stealth and shadowy moves of a street-level dealer, American pharmaceutical companies have moved their turf to new, mostly naïve markets to sell their wares. They have done this to escape the federal regulations that have limited their market; a response to the opioid crisis that has seen hundreds of thousands of lives affected by substance use disorder or lost to overdose.

India is one country that has seen a significant increase in opioid availability. Despite being one of the world’s top producers of opium for legal distribution, access to opioids for those who needed it was severely lacking. Access to morphine and other opioids for patients with cancer or other painful diseases was among the lowest in the world. India’s Narcotic Drugs and Psychoptropic Substances Act of 1985 enacted major penalties for manufacture, distribution and possession of opioids as well as a great deal of bureaucratic red tape around prescribing. A reappraisal of these strict laws in 2014 helped to change that and improved access to opioids for patients and made it easier for doctors to prescribe these drugs.

This coincides with the time that the current opioid epidemic was starting to become apparent in the United States. The influx of fentanyl into the supply chain fueled by unchecked access to opioids like oxycodone and hydrocodone has resulted in an epidemic of substance use and loss of life. As a result, there have been regulations at every level of the supply chain. Pharmaceutical companies have been the target of lawsuits, over two-thousand suits all bundled into one National Opiate Litigation case, claiming harms from marketing and sales, and more actions are likely on the horizon.

Purdue Pharmaceuticals, run by the Sackler family, has avoided involvement by settling with plaintiffs. In doing so, they filed Chapter 11 and for the time being blocks any further actions against the company. This was just one of several tactics they used to make sure they keep a large part of their Oxycontin-fueled bankroll. Which brings us back to India and a company called Mundipharma.

Mundipharma International is a global pharmaceutical company owned by the Sackler family. It has a major presence in India and has been responsible for flooding the market with buprenorphine and tramadol. Both drugs are widely available and becoming part of an ever-growing problem with substance use disorder in India and in other developing countries. While less addictive than Oxycontin, these drugs are opioids and have the potential for misuse and addiction. They are doing this using some of the same tactics they used to market Oxycontin and they are doing it despite knowing the harms. The turf has changed, the drugs have changed but the same tactics and same names are at play. Johnson and Johnson and Abbott pharmaceuticals, also plaintiffs in the National suit, are peddling their wares here too.

Access to these drugs is further fueled by the lack of regulation in India. While these drugs require a prescription, they are often available without one. A person can walk right into a pharmacy or even a kiosk in a market and ask for these drugs without a prescription or any other documentation. This is all coupled with the close proximity to heroin trade routes from Afghanistan and Pakistan, as well their own opium production.

What this all means is that pharmaceutical companies may have cleaned up their act in the United States, but they have continued their sinister ways in the more shadowy corners, hoping that no one notices they are there. Using methods akin to those that fueled the Oxycontin epidemic, these companies are pushing large quantities of opioids in a market that lacks the protections and regulations needed to prevent an opioid epidemic like the one the United States is now facing.

The risks of this are clear. One is that unregulated access can lead to an epidemic of addiction and death. Second is that India could face what we in the United States are now facing; a pendulum swing that has reduced legitimate access to opioids for those patients who need them; chronic pain and palliative care patients. These are the very patients that have suffered for decades in India owing to lack of access. These companies, Purdue, Abbott, Johnson and Johnson among others have simply shifted their corner and evaded the regulations that have them in so much hot water in the United States. When it comes to pushing drugs, its all about turf.



Stephen Wood

Stephen P. Wood, MS, ACNP is an acute care nurse practitioner practicing emergency medicine in Boston, Massachusetts, and a fellow in bioethics at the Center for Bioethics at Harvard Medical School in Boston.

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