Mapping the Opioid Crisis | MLP Map

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Team Holarchy -Opioid MLP Map

22 min readMar 27, 2019

Introduction

Team Opioids approach to mapping the social niches, regimes, and landscapes that contribute to the Opioid crisis were approached in an individualistic approach. Each team member had a focus area which they became experts within their specific domain. Listed below are the division of labor our team took.

Ekta- Technology
Michelle- Social
David- Environment
Patrick- Healthcare
Jo- Economics
Sofía- Policy

These subtopics are directly taken from our wicked problem map. We believe that this was the best strategy to utilize.

Process

After each person’s self-directed investigation and research, we came together as a team and shared our findings. We mapped our post it’s and saw many different connections and themes emerge. Over the course of three meetings, we came together and educated each other on each topic. Once we all were on the same page and familiarized each other with our research, we started organizing our map. We identified key time periods, themes, and concepts for intervention. After the physical form gave shape we decided to individually divide and conquer the connections in a digitized way.

We digitized our map and individually made connections to all relevant issues we saw connected to our topic. Our end product is a collection of unified thoughts that will pave the way for a holistic and synergistic solution.

Opioid crisis analyzed through a Multi-Level Perspective (MLP)

Zoom section 1: Opioid crisis analyzed through a Multi-Level Perspective (MLP)

Zoom section 2: Opioid crisis analyzed through a Multi-Level Perspective (MLP)

Historical factors to the wicked problem at all three levels

After coming together and sharing relevant research we had a meaningful and deep conversation that illuminated the major themes and time periods that directly influenced and affected the opioid crisis.

The major time periods are listed below:

3400BC
1800s
1990s
2001
2003
2016
2019

To give a more thorough explanation of our subtopics included in our MLP map, each member individually wrote on their domain knowledge. Themes emerged through each subtopic and are presented below. Subtopics listed below include technology, social, environment, healthcare, economics, and policy.

Technology

An improvement in Technology led to a mechanistic mindset. People got alienated to the concept of the human and started seeing things from a very mechanical mindset rather than a holistic mindset. Doctors started seeing patients as an entity to be treated rather than seeing them as a human. They started prescribing opioids for every sort of a pain to get through patients quickly rather than giving them more personalized care. There were a lot of developments at the niche level, such as syringes etc, which focused on use-and throw technology, which further helped propagate this mindset.

There was an improvement in transport technology. Blue-collar workers usually worked on the construction to enable this enhanced transportation. More construction led to more injuries of the workers, which led to more morphine being prescribed as pain-killers to help them deal with their injuries.

An improvement in transport technology led to a subsequent increase in trade and movement across barriers. The silk route opened up and the US saw an influx of poppy seeds from Mexico and other countries.

The digital revolution bought cheap and easily available devices in the market. The DOT COM Bubble brought internet to the hands of people, people started using these devices to tap into these networks. This made opioids highly accessible to people as they could easily find them on the internet. Government regulations were slow to come up with regime level regulations to monitor the internet, misuse had already started by the time they did.

In general, science and technology developed, and new methods of scientific testing came into use, Scientists were able to test for traces of drugs in the environment and came up with startling statistics regarding the presence of trance opioids in mussels and fishes due to human waste containing drugs being washed into the water bodies. This led to an increase in awareness when it comes to drug abuse.

The DotCom bubble was followed by a period of recession. The recession saw people lose their jobs and get into addiction to deal with their emotions. The increased access to the internet further propagated this surge in the increase of opioids.

Introduction of Text messaging in the early 2000s also further pushed the opioid crisis as communication channels started forming.

In recent days technology has been used creatively to deal with addiction, lots of new apps and websites are being introduced to improve people’s access to help and organizations that help deal with addiction. Technology is also being used to track potential drug addicts or monitor the pharmaceuticals that tend to indulge in illegal opioid trade. There has been a flurry of government at the niche level, but there have been hardly any regime level interventions due to widespread corruption still penetrating the law-making bodies.

Social

From the Social perspective, the opioid crisis can be traced back to 2727 B.C. when cannabis was first recorded as medicine in Chinese pharmacopoeia. This is the first instance when a drug was recorded for medicinal purposes. In terms of opiates, research shows that our current opioid crisis can be traced to the first wave of addiction that swept the U.S. in the late 19th century. Beginning in 1805, German pharmacist Friedeich Serturner isolated morphine from opium, the first “opiate” (the term opioid once referred to purely synthetic morphine-like drugs. Thus during the 19th century, physicians got their hands on morphine: a truly effective treatment for pain. With no criminal regulations on morphine, opium or heroin, many of these drugs became the “secret ingredient” in readily available, effective medicine. In such a climate, a popular so-called “patent medicine” market flourished and illegal use of the drug was rampant.

Seeing as there was no Food and Drug Administration (FDA) to regulate the advertising claims of health products more than 100,000 people were considered as medical addicts to morphine. It was not until 1906 when the FDA was created that there became stricter regulations on drugs. That gave rise to what would become the Food and Drug Administration, as well as the notion that food and drug products should be labeled with their ingredients so consumers could make reasoned choices.

Regime level intervention started to take hold after the FDA was formulated. This included many drug regulations and stricter laws that came about banning illicit drug use seen on our map.

The second wave of our opioid crisis began during the late 80s to early 90s. This happened through the eschewing of direct marketing to the public, including advertising in medical journals. It wasn’t until 1995, when Purdue Pharma successfully introduced OxyContin “OxyContin passed because it was claimed to be a new, less-addictive type of drug”. Pharma was allowed to encourage this campaign because they quoted New England Journal of Medicine’s letter that stated “Addiction rare with patients treated with narcotics”. This landscape article changed the way marketing companies marketed OxyContin.

This segways our social conversation the Sackler family. The Sackler family are descendants of Isaac Sackler and his wife Sophie, who were immigrants from Ukraine and Poland. The couple had three sons, Arthur, Mortimer, and Raymond Sackler who each went to medical school and became psychiatrists. In 1952, the brothers bought a small pharmaceutical company, Purdue Fredericks, in Connecticut. Arthur, the oldest brother, became a pioneer in medical advertising. After his death in 1987, his option on one-third of that company was sold by his estate to his two brothers. Many of the Sackler family members served on the Purdue board for years between 1990 and 2018, as the company created, launched and marketed OxyContin to replace a morphine-based drug that had its patent expire.

Since the rise and sales of Oxycotin hundreds of deaths have occurred. With the rise in social media, we are now more informed than ever about the escalating Opioid Crisis. thousands of protests have surfaced and we are now getting more insights on how involved the Sackler was in the opioid epidemic.

Environment

From the environmental perspectives, the opioid crisis can be traced back to the birth and the early use of poppy, the raw material for the opioid. Poppy was first cultivated in the Middle East in 3,400 BC. The dry and warm weather in the area fertilized the plant. People soon found out the scent of poppy could easily allure them. In the landscape level, therefore, people viewed poppy as a “Joy Plant”. The dominating attitude towards poppy led to the wide cultivation of poppy in the Middle East. In the niche level, Greek and Egyptian physicians discovered poppy’s pain release effect and applied poppy to cure pain for their patients. At the same time, transportation improvement in the landscape level incentivized trade among different countries. In the regime level, the development of Silk Road allowed merchants to bring poppy from the Middle East to China, where poppy was used for producing opium. Opium soon became popular in China in the early 1800s. Nevertheless, in the regime level, the Qing Government in China discovered the negative effect of opium addiction on the country’s economic growth and decided to destruct opium and close the trading with the middle east and the rest of the European countries. In 1839, the Qing government destroyed 1016 tons of opium at Humen. This niche level event affected the interests of opium traders in Great Britain. Following the destruction of opium, Great Britain initiated two Opium Wars in the regime level to force China to open up the borders for trading. At the same time, Chinese immigrants brought poppy to Mexico and Latin America, who later became the major raw material suppliers for the opioid. In the niche level, the technological improvement allowed the scientist to extract Morphine (1803), Oxycontin (1939) and other major elements for addictive drugs from the poppy. The development of these drugs fed into the regime level to facilitate the establishment of FDA and other regulations.

The global warming trend dominated the environmental transition in the 20th Century. In the landscape level, global warming allowed people to easily grow poppy in areas like South Asia and Mexico. The abundant raw materials allow pharma to produce opioid products, which finally resulted in the opioid epidemic. In the early 2000s. when scientific research and statistics indicated the harm caused by opioid and other poppy-related drugs in the niche level, the regime level was forced to transition. The government in South Asia and Mexico attempted to introduce alternative crops to the poppy farmers for them to replace the poppy farm. In the landscape level, people’s attitude towards opioid and poppy changed, which led to multiple protests and lobbying in the regime and niche level. At the same time, technological improvement enabled scientist to found out opioids’ negative impact on the environmental: water in some part of the U.S. was detected to have opioid-related pollutants, more female and intersex fishes were found in the downstream, and in Seattle, mussels were detected positive for the opioid. These niche level discoveries and protests affected the regime level to force the government to make a transition. As a result, the current U.S. government declared opioid a public crisis in 2017.

Healthcare

Several coinciding factors shaped the healthcare system in the United States. These factors are what made the healthcare industry in the United States so highly privatized, unaffordable, and lucrative. Without a doubt, the inherent capitalist mindset embodied by Americans played a big role in the privatization of healthcare. However, there are plenty of countries that believe in capitalism, such as Canada, Switzerland, France, and the UK, just to name a few, that offer cheaper, more accessible healthcare. Therefore, there isn’t enough justification when we say capitalism is the only reason the American healthcare system is the way it is right now.

On the landscape level, there are three other key factors that contributed to the privatization of healthcare in the United States. One of these factors dates back to when the United States established its independence. During that time, the issue of healthcare was not mentioned in the Constitution. In other words, the responsibility of providing healthcare to the citizens of the nation was not laid out and was therefore not delegated to any level of government. Healthcare was not ensured locally, at the state level, or federally. Because of this, no level of government has been tasked with the responsibility of providing and ensuring healthcare for everyone. As a result, the free market has taken over and provided citizens with the first instances of care and treatment. The second factor that largely contributed to the privatization of healthcare is the increases in technology around the globe. Countries started building railroads and utilizing newer, more efficient modes of transportation. The construction of these railroads and other infrastructures led to a lot of injuries while on the job. In these situations, private healthcare services were able to immediately step in and help workers and treat their injuries. The last factor contributing to the privatization of healthcare is the Cold War. The battling of ideologies, one that focuses on the freedom of choice and one that focuses on communistic ideas, has led the United States to stray away from following in the footsteps of the Soviet Union, such as Germany, which employs universal healthcare.

These entities on the landscape level (Global pressure towards capitalism, American Independence, technological advances, the Cold War) has influenced regime level activities and mindset. From a cultural standpoint, it has largely influenced and reinforced the United States’ freedom of choice mindset, which in return has brought upon free market ideologies in industries across the nation. Along with the creation of private healthcare services was also the creation of private pharmaceutical companies, who were in charge of developing and creating medicinal remedies for patients. As a response to ensuring private interests aren’t affecting public wellbeing in a negative way, the American government established the FDA to set out regulations to ensure public safety.

As healthcare got more and more expensive and more privatized, opioids became a quick and easy short-term remedy for treating chronic pain, as opposed to spending time and money on physical therapy. Additionally, injured citizens started to use the Emergency Room a lot more as it was, at most times, the only available option for immediate treatment. As a direct result of this misuse, patients were mainly prescribed with painkillers to deal with pain instead of being treated for the injury itself. As the cost of healthcare spirals and becomes increasingly expensive, we see actors at the niche level take action to remedy this issue and make healthcare more affordable. For example, as part of Obamacare, Obama issued the individual mandate, which required (to a certain extent) American citizens to purchase health insurance, whether they are healthy or not, in order to drive the price of healthcare down for everyone else. This mandate failed as it clashed with the United State’s cultural ideology of freedom of choice and free-market opportunities. However, due to technological advances, we start to see people self-diagnosing themselves through the use of the internet, using WebMD, for example, all as an alternative to receiving healthcare and health treatment the traditional way.

Economics

The fundamental drive on the landscape level is economic growth and profit-driven capitalistic mindsets around the early 1900s. Wealthy families, such as the Sacklers, influence in Purdue Pharma is at the center of this opioid epidemic. Existing marketing and sales techniques of pharma industry, business networks (distributors, manufacturers, dealers, doctor/physician networks), government relations (FDA, EDA, joint commission, etc) enabled big pharma to push painkillers to tens of thousands of patients in the US alone.

Pharmaceutical companies’ lobbying and marketing techniques were able to educate the medical community, as well as patients, on the changing of their attitudes on pain treatment.

In the 1980s, there was a major shift in mindset in the medical community regarding pain treatment. A more compassionate approach to expanding treatment of pain from cancer to all kinds of pain penetrated mainstream medicine. Physicians/doctors began promoting the use of these drugs for all types of common pain. The Sackler family saw this as an opportunity and therefore decided to get involved with the pharmaceutical industry.

In 1996, the same year OxyContin hit the market, the American Pain Society — an advocacy organization funded by pharmaceutical companies — began a campaign to expand medical care for pain based on the idea that it is the body’s “fifth vital sign,” along with traditional markers like body temperature and blood pressure. In 2001, the Joint Commission — a federal agency that sets medical practice standards — introduced an updated approach to patient care stating that doctors should always address pain; not doing so, the commission found, meant doctors weren’t doing their job appropriately. Soon, patients were rating doctors on how well they addressed their pain, a score that insurance companies used to help determine whether to include a physician on their plan. The physicians were told by FDA that they were required to treat pain. However, they weren’t given any tools, which could have included cognitive behavioral therapy, acetaminophen, and pain tolerance. All they had were opioids.

There was also a systematic deception of doctors/misrepresentation of the danger of the painkillers. Many physicians were clueless about the addictive nature of the painkillers that they were prescribing. This is largely due to pharma companies training and sending thousands of sales reps to doctors and physicians’ offices to push them over and have them prescribe the highest dosages possible — quantities that far outweighed any genuine medical need. Purdue Pharma marketed OxyContin deceptively, doctors were educated to believe that OxyContin is a “safer drug”, “better drug”, which should be used more liberally for all sorts of pain. Capitalist mindset drilled down to an individual level, causing sales reps, even doctors/physicians to be driven by the highest monetary gains possible. Furthermore, the existing sales compensation model, that sales rep are compensated with a high premium on selling the highest dosages, exposed patients to the greatest risk of opioid addiction.

On the other hand, political corruption (lobbying/pharma business influence on policy) played a major role in the opioid epidemic. For years, big pharmaceutical companies were able to successfully protect themselves and influence policies that favored their capitalistic agendas by hiring the best lobbyists, lawyers etc. Purdue Pharma pressured the FDA to ignore the lack of science supporting long term use of OxyContin. Purdue approved this in 1995 and had the FDA give a green light to push opioid to tens of millions of patients nationwide. Through lobbying, pharmaceutical companies pressured Congress to limit agency enforcement power and DEA (Drug Enforcement Administration) lawyers into taking a softer approach.

Pharmaceuticals were also able to use public relation strategies to attack people who become addicted to OxyContin and claim that it’s the addicts that are to blame, shifting the public focus from pharma to addicts themselves. This influenced the stigma of blaming the abusers on the landscape level.

Protest in museums and educational institutions that received a large number of donations from Sacklers hopefully will motivate/inspire public officials, lawyers, journalists, to act in public interest — disclose documents showing pharma industry knew the addictive effects of painkillers. This rise of lawsuits will raise public awareness and will push pharma to end sending a sales rep to doctors’ offices and false advertising on public media.

Policy

The opioid crisis has been exacerbated by a lack of political will to tackle pharmaceutical companies and their multi-million dollar business. The aim of pharma companies to indiscriminately grow and constantly boost their revenues is rooted in a neoliberal capitalist ideology that has led to the privatization and commercialization of health. In a very basic approach is the more pills that are sold, the more revenue the pharma companies accumulate. The overprescription of medicines as Oxycontin and Vicodin during the 1990s became the norm in doctor’s offices and to this day, pharmaceutical sales representatives are one of Big Pharma’s biggest leverage points.

This ideological turn in the privatization, mechanization, and commodification of human health and addiction is what can be distinguished as the political landscape level, rooted in the sociotechnical developments of the 1800s, and deeply present still today. Thus, this is what was portrayed by the Sackler scandal and investigation during the 2000’s –starting in 2001– and which still is under public scrutiny. Per legal investigations, opioid addiction was designed and micromanaged by Purdue Pharma and the owning family, the Sacklers, in order to increase revenues and profits. The disregard for the human and social aspect of prescribing high dosage opioids for chronic pain has been continuous and sustained in the past three decades. The consequences have been overlooked for many years in the chase of financial benefits, disregarding core causes and actions that have build into a national epidemic.

In 2017, President Trump declared the opioid crisis as a national emergency. This unleashed a series of Federal acts and legal actions led by a Republican-dominated Congress. Nevertheless, these acts have had little impact and have only reinforced the regime level. The Comprehensive Addiction and Recovery Act 17, as well as the Support for Patients and Community Act consider relevant points as creating social support networks for addicts and opioid users. The outcome of these legislations was the Trump administration created a digital platform “The Crisis Next Door” for the general public to understand the large-spread of the epidemic. Nevertheless, initiatives like a website, remain quite isolated interventions if not complemented with major communication or awareness campaign. Another restraint for the epidemic to be tackled through the signed acts is the lack of funds. No additional finances were released to implement a congruent encompassing Federal program to tackle the crisis. Other isolated interventions have been the shut down of pill mills, thanks to the activity of whistleblowers, by the FDA and DEA.

At the niche level, local initiatives have been developed to tackle the crisis in a more immediate and far-reaching way. The more prolific interventions have come at the state and city level. In response to the lack of Federal support, six states –Alaska, Arizona, Florida, Maryland, Massachusetts and Virginia– and tribal leaders declared themselves in a state of emergency in regards to opioid consumption. This allowed them to release special funding to create acupunctural interventions that range from prescription guidelines and scaling back in the prescription of painkillers, to punctual litigation against manufacturers and distributors of opioids. Many of these actions have been accompanied by communication campaigns, with the purpose of shifting perceptions mainly in doctor’s offices and by the general public. Inspiration has been withdrawn from the tobacco example.

Finally, a particularly interesting example at the niche level is the state of Ohio. With the 5th highest opioid consumption rate in the country, they approached the problem in a different way than the rest of the country. The Governor’s Cabinet Opiate Action Team (GCOAT) was created in order to tackle the crisis in an encompassing and holistic way. Besides the already existing approaches of litigation as a response to fight the intrusions and meddling of big pharma and lowering prescriptions, they have boosted the psychosocial treatments (therapies) accessible through Medicaid, developed needle exchange programs, invested funds in treatment programs, created non-prescribed access to naloxone (a medicine used when opioid users overdose). They have also identified the importance of pharmacists as actors in the frontline of the problem, caught between patients and doctors. They have direct contact with patients, understanding their needs and preoccupations. In parallel, they can identify over-prescribing patterns from doctors and illegal actions. To support pharmacist, GCOAT created the “Sometimes we just have to say no” campaign, which gives them enforcing and recognition guidelines while dealing with patients and physicians.

Finally, progressive programs as SIFs (Safe Injection Facilities) in Seattle and King County (city and county level bound programs), have helped mitigate the impact of the epidemic in other social and urban ramifications. Yet, they have not been adopted in other parts of the country due to their values and mindset controversial nature.

Difficulties and Insights

The difficulties that we encountered were few and far in between. The hardest part was organizing ourselves on how we could divide our individual parts in terms of research, writing, and digitizing/organizing the MLP map. Ultimately we found a great group cohesion and individually mapped and wrote about our own separate domain knowledge to produce a holistic and intricate map at the landscape, regime, and niche level.

Conclusion: Proposed sites for intervention

Overall, we found the Opioid Crisis to have many landscapes, regime, and niche level factors involved. Already we see intervention points that can help alleviate this systems-level problem. For this, we identified 4 pseudo-satisfiers, from Manfred Max Neef’s matrix of human needs, present in the Multi-Level Perspective (MLP) mapping, in order to understand some of the historical pinnacles present in our research:

1| Pseudo satisfier: Mechanistic Medicines (need: protection)
By creating a compartmentalized approach to health and medicine with “a pill for every ill” approach, where the human and social aspect of creating a micromanaged approach to pain killer prescription.

2| Pseudo satisfier: Stereotypes (need: understanding)
Addicts and patients are stereotyped as carrying the whole responsibility of their addiction. On the other side, whole populations are stereotyped as heavy opioid consumers. Usually, these stereotyped communities are the most vulnerable ones (living in poverty with restricted access to full health care benefits, as psychosocial therapies).

3| Pseudo satisfier: Fashion & fads (need: identity)
During the 1990s and 2000s, the prescription of opioid-based pain-killers became the norm.
A lack of medical forecasting and misleading by big pharma drove health practitioners, doctors, to overprescribe opioids.

4| Pseudo satisfier: Status and symbols (need: identity)
Who has access to healthcare and to insurance? This is determined by the socioeconomic capabilities of individuals, which in return has become a symbol of social and class status.
Families under a particular economic threshold have to be enrolled in Medicaid, while more affluent families have the possibility to access private medical insurance with larger coverage.

Intervention points & synergistic satisfiers

Once the pseudo-satisfiers were identified, we diagnosed areas of opportunity for interventions where synergistic satisfiers could be developed.
In an attempt to connect different theories of change reviewed during class, we are identifying the areas of opportunity through the MLP map, referencing them back to Donella Meadows leverage points and connecting them to Max Neef’s matrix of Human Needs:

1| Therapies: e.g. Cognitive Behaviour Therapy
New approaches to health care where the wellbeing of the patient is the central concern, regardless of the longitude of the treatment. Addressing medical issues in this way might sparkle a virtuous cycle instead of creating negative impacts in other areas of the patient’s life. Also, care solutions could be framed through particular cultural mindsets (e.g. indigenous wisdom)

Leverage Point 3 |Changing the goals of a system
Needs it responds to |Subsistence, Protection, Affection. Identity

2| Increased government intervention
Increasing government control and regulation over the use of the internet could be an important leverage point. Currently, the government controls the internet but in a very loose way, the main power is with the people, this allows for misuse in certain niches and pockets. Our suggestion pushes towards a more centralized mechanism of control and stricter vigilance on internet activity, however, it is key that this monitoring happens in a transparent way and citizens are made well aware that they are being monitored.

Leverage Point 4 | The power to add, change, evolve or self-organize system structure
Needs it responds to | Protection, Understanding, Participation

3| A more acute assessment of pharmaceutical companies’ success
Focusing on how healthy patients are after the consumption of particular pain killers. Assessing recovery and mortality rates, and scrutinizing pharmaceutical companies’ aims through the distribution of those medicines in the market and in doctor’s offices.

Leverage point 5 | The rules of the system (such as incentives, punishments, constraints)
Needs it responds to | Understanding, Protection, Freedom

4| Shifting roles/agency
Understanding patients and pharmacists role differently. Both actors are central stakeholders in the process and in the front line of the problem, which makes them pivotal in looking for solutions.
These may come as a series of external interventions where they may be involved, e.g. participatory processes, new forms of approaching the problem through education, generation a sense of agency and a shift in decision making.

Leverage point 4 | The power to add, change, evolve, or self-organize system structure
Needs it responds to | Subsistence, Protection, Affection, Understanding, Participation, Creation, Identity, Freedom

5| Cooperative health
New community organized clinics and publicly owned health care. A model based on the commons and a shared, self-regulated asset of the community.

Leverage Point 2 & 4 | The mindset or paradigm out of which the system –its goals, structure, rules, delays, parameters– arises & The power to add, change, evolve, or self-organize system structure
Needs it responds to | Subsistence, Protection, Understanding, Participation, Creation, Identity, Freedom

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REFERENCES

Policy research
Gostin L.O., Hodge JG, Noe SA. Reframing the Opioid Epidemic as a National Emergency. JAMA.2017;318(16):1539–1540.

Hodge, J. G., Wetter, S. A., & Noe, S. A. (2017). Emerging Legal Responses to Curb the Opioid Epidemic. The Journal of Law, Medicine & Ethics, 45(3), 460–463.

Pain medicine — anesthesiology; study results from oregon health and science university provide new insights into anesthesiology (the US opioid crisis: Current federal and state legal issues). (2017, Dec 22). Food & Drug Law Weekly.

Lopez. (2019, February 06). The opioid epidemic is a crisis, but Trump isn’t treating it like one. Retrieved March 27, 2019.

Stories of the Opioid Epidemic. (n.d.). Retrieved March 27, 2019.

Tanzi, A. (2019, March 21). Fentanyl Increasingly Source of U.S. Drug Overdose Deaths. Retrieved March 27, 2019.

The US Opioid Crisis: Current Federal and State Legal Issues : Anesthesia & Analgesia. (2017, November). Retrieved March 27, 2019, from

Young, A.L. (Producer). (2019, March 15). The Family That Profited From the Opioid Crisis [Podcast]. In The New York Times. New York, NY: The Daily.

“OxyContin Marketing Plan, 2002.” Purdue Pharma, Stamford, CN, 2002

Cicero T, Inciardi J, Munoz A. Trends in abuse of OxyContin and other opioid analgesics in the United States: 2002–2004. J Pain 2005;6:662–672 [PubMed] [Google Scholar]

Oxycodone and OxyContin. Med Lett Drugs Ther 2001;43:80–81 [PubMed] [Google Scholar]

Hale ME, Fleischmann R, Salzman R, et al. Efficacy and safety of controlled-release versus immediate-release oxycodone: randomized, double-blind evaluation in chronic back pain. Clin J Pain 1999;15:179–183 [PubMed] [Google Scholar]

Kaplan R, Parris WC, Citron MI, et al. Comparison of controlled-release and immediate-release oxycodone in cancer pain. J Clin Oncol 1998;16:3230–3237 [PubMed] [Google Scholar]

Staumbaugh JE, Reder RF, Stambaugh MD, et al. Double-blind, randomized comparison of the analgesic and pharmacokinetic profiles of controlled- and immediate-release oral oxycodone in cancer pain patients. J Clin Pharmacol 2001;41:500–506 [PubMed] [Google Scholar]

Heiskanen T, Kalso E. Controlled-release oxycodone and morphine in cancer related pain. Pain1997;73:37–45 [PubMed] [Google Scholar]

Mucci-LoRusso P, Berman BS, Silberstein PT, et al. Controlled-release oxycodone compared with controlled-release morphine in treatment of cancer pain: a randomized, double-blind, parallel-group study. Eur J Pain 1998;2:239–249 [PubMed] [Google Scholar]

Bruera E, Belzile M, Pituskin E, et al. Randomized, double-blind, cross-over trial comparing safety and efficacy of oral controlled-release oxycodone with controlled-release morphine in patients with cancer pain. J Clin Oncol 1998;16:3222–3229 [PubMed] [Google Scholar]

“New Drug Application for OxyContin.” Purdue Pharma, Stamford, CN December 1995.

Chou R, Clark E, Helfand M. Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain. J Pain Symptom Manage 2003;26(5):1026–1048 [PubMed] [Google Scholar]

“OxyContin Marketing Plan, 1996.” Purdue Pharma, Stamford, CN.

“OxyContin Marketing Plan, 1997.” Purdue Pharma, Stamford, CN.

“OxyContin Marketing Plan, 1998.” Purdue Pharma, Stamford, CN.

“OxyContin Marketing Plan, 1999.” Purdue Pharma, Stamford, CN.