A decade ago, as opioid painkillers fueled a growing addiction crisis across the nation, Philadelphia stood out as one of the most ravenous consumers of the most potent pill on the market: OxyContin’s 80-milligram payload of the drug oxycodone.
Rural states had been OxyContin’s beachhead after it was introduced, but by 2009, pharmacies in Philadelphia and its suburbs ordered the Purdue Pharma drug at a rate twice that of West Virginia, and higher than nearly anywhere else in the nation.
Philadelphia’s peak came two years after Purdue admitted in court that it falsely claimed its extended-release pill was safer and less addictive than other opioids.
Then the company reformulated the drug in August 2010 into an “abuse-deterrent” OxyContin: one that, when crushed, turned to a gummy mush instead of a fine powder, keeping users from snorting or injecting the drug to get its high all at once.
Across the nation, OxyContin sales dropped slightly, indicating that while some customers preferred the crushable drug, most patients accepted the safer formulation. But in Philadelphia, sales dropped four times faster than the rest of the country — a red flag that the drug had been widely abused here.
Philadelphia pharmacies that were the biggest orderers of the crushable drug cut their orders significantly — or almost completely.
An Inquirer analysis of the Drug Enforcement Administration’s records of shipments of OxyContin and other controlled substances between 2006 and 2012 brings to light, for the first time, the Philadelphia retailers buying the drug — and how much of it was likely being abused.
The consequences are being felt to this day. When the supply of crushable OxyContin dried up, many users turned to Philadelphia’s cheap and plentiful heroin to slake their opioid addiction.
In Philadelphia, overdose deaths involving heroin increased at nearly twice the rate of the rest of the nation. Last year, Philadelphia saw 1,116 people die from overdoses, the worst drug crisis of any large city in the nation.
“You can draw a straight line to the death and destruction we’re seeing on the streets of Kensington today and the decision made in the boardroom at Purdue Pharmaceutical and other companies,” said Pennsylvania Attorney General Josh Shapiro, referring to the drug’s prevalence in the region — and the intense marketing he said Purdue engaged in in Pennsylvania.
Shapiro has joined Pennsylvania with 23 states — New Jersey among them — in filing a lawsuit against members of the billionaire Sackler family, which owns Purdue. The company itself is now in bankruptcy proceedings, brought on by enormous settlements with local governments over allegations Purdue helped ignite today’s opioid epidemic — one that is playing out with horrific cost in Philadelphia.
Inflating the opioid market
When Purdue introduced OxyContin in 1996, it was hailed as a miracle drug for people with chronic pain. Unlike existing “instant release” oxycodone drugs, a pill of OxyContin, when swallowed, released the drug gradually over the course of 12 hours, supposedly minimizing the euphoric highs — and intense withdrawals — that Purdue said caused opioid addiction.
Doctors had long shied away from prescribing addictive opioids except for the most severe pain, such as what cancer patients might experience. So the company sent sales representatives to all kinds of doctors to assure them the extended-release drug was safe for more common ailments like back pain.
Over the next few years, as prescriptions for OxyContin soared, the drug developed a reputation for abuse in rural communities. The federal government began investigating Purdue, and in May 2007 it extracted a $634 million settlement from the company and its executives.
“Purdue's claims that OxyContin was less addictive and less subject to abuse and diversion were false — and Purdue knew its claims were false,” U.S. Attorney John Brownlee said at the time.
That settlement wouldn’t be the end for OxyContin.
According to a DEA database that tracks each shipment of controlled substances called Automation of Reports and Consolidated Orders System, or ARCOS, OxyContin made up just 13% of the prescription opioids in 2007 that had oxycodone or hydrocodone, the ingredients in the most prevalent opioid pills.
But just a year after Purdue pleaded guilty, OxyContin’s share of the national opioid painkiller market would double to 28% of the market’s total “morphine milligram equivalents,” or MMEs, a standard measurement of how much addictive substance a patient is receiving, according to the DEA’s database.
OxyContin’s growth, however, didn’t come at the expense of opioid competitors. Their oxycodone sales remained more or less flat.
Compared with sales in the rest of the country, oxycodone drugs were much more popular in Philadelphia and its surrounding counties. Shipments of OxyContin, for example, accounted for more than 45 percent of all the MMEs shipped to Montgomery County pharmacies for much of 2008 and 2009. The majority were OxyContin’s maximum-strength pills.
A single pharmacy in Cherry Hill ordered more than a quarter million OxyContin pills alone in 2009 — outstripping total orders in 85 percent of counties nationwide.
Compared with all other counties with more than 250,000 residents that year, Philadelphia and its suburbs got more OxyContin than nearly every one of them, particularly the 80-mg version. That was a pill the Food and Drug Administration warned was so powerful that it could kill people who hadn’t built up tolerance to opioids.
The bubble pops
In the weeks leading up to the reformulation of OxyContin in summer 2010, Ihsanullah Maaf’s Northeast Pharmacy ordered Oxy 80s at an increasingly frantic pace.
Since opening in 2008, the pharmacy placed the majority of its opioids orders for OxyContin, usually at maximum strength. That summer, from its base in a rundown strip mall, the business ordered more Oxy 80s than nearly any other pharmacy in the nation.
Northeast Pharmacy’s customers included Kyle Jones. He was a low-level player in a drug-trafficking network that relied on people like him to get doctors to write them oxycodone prescriptions, fill them at drugstores, then funnel the pills directly to street dealers. (Law enforcement had for years seen OxyContin showing up on the streets, where an 80-mg pill could sell for $80.)
On a day that summer when Maaf ordered 1,200 maximum-strength OxyContin pills, Jones was several miles away in the Montgomery County office of Dr. Norman Werther. Prosecutors later said the doctor coached Jones on what he should say in order to get a crushable opioid pill, rather than the reformulated OxyContin.
“If you have problems with the new pill, let me know — if you have any stomach pains or anything, and the next time you have a visit I’ll change the pills,” Werther said, according to Jones’ later testimony in court.
Sure enough, on a return visit a month later, Jones complained that the new pills were making him throw up. So Werther put him on crushable, 30-milligram oxycodone tablets.
Maaf, Werther, Jones, and many others were eventually convicted for their roles in drug networks that pumped enormous amounts of OxyContin and other drugs into the streets of Philadelphia. (Werther has since died.)
For most pharmacies, even in Philadelphia, the reformulation of OxyContin made virtually no difference — a sign that their customers were using the drug as prescribed. But the vast majority of the city’s OxyContin wasn’t shipped to those pharmacies. Most of it was ordered by just a handful of drugstores.
Even Purdue acknowledged that massive sales declines in abuse-resistant OxyContin were a signal that many of its pills had been abused.
Pharmacies that stopped ordering OxyContin immediately after the reformulation could be “involved in a situation where abuse and diversion may have been prevalent,” said Stephen Seid, then Purdue’s director of national accounts, in a deposition in the Purdue lawsuit earlier this year.
“The theory being that proper users of OxyContin didn’t have a problem with the reformulated drug because they weren’t planning to crush it?” asked a lawyer for the State of Tennessee.
Seid replied: “Most didn’t, right.”
When OxyContin was reformulated, Philadelphia’s orders dropped by a third within a couple of months. Nearly all of that reduction was driven by a handful of pharmacies like Maaf’s.
People addicted to OxyContin could still simply swallow the drug. And determined users could bypass the abuse deterrents, albeit with some difficulty. But it was far more convenient for many drug users to seek out opioids in other forms.
"The crush-proof [formula] is critical — if OxyContin isn’t crushed, from a recreational standpoint, it becomes less attractive,” Michael Lynch, medical director of the Pittsburgh Poison Center, said in a recent interview.
Another Philadelphia retailer that followed this pattern was E-Glam Pharmacy, in Germantown — 99.7% of the OxyContin it ordered in 2010 came in 80-mg pills.
Two months after OxyContin was reformulated, the pharmacy never ordered a single 80-mg tablet again.
E-Glam owner Inyang Inyang said when contacted recently that he doesn’t remember everything his now-shuttered pharmacy did in 2010. He did not respond further when a reporter provided records of his orders.
For years, Verree Pharmacy in Fox Chase ordered more oxycodone than nearly any other pharmacy in the nation, ARCOS data show.
By the time the crush-resistant OxyContin had been out for a year, Verree was ordering half as much OxyContin as before.
But it would continue to order suspiciously large quantities of oxycodone from other manufacturers. In October, the DEA served Verree a warrant, after the pharmacy’s supplier began to report suspicious orders and practices to the DEA. Owner Mitchell Spivack declined to comment.
‘People will find an alternative’
When crushable OxyContin disappeared, the addictions it had fueled did not.
“If you take a medication we suspect that was highly diverted, and you change it so it's not so attractive for diversion,” Lynch said, “people will find an alternative.”
Northeast Pharmacy moved into the next-highest-dose pill that was still crushable: 30-mg pills of oxycodone, manufactured by Purdue’s biggest competitors, Mallinckrodt and Allergan. Maaf operated for another full year before the drug ring was shut down.
A year after OxyContin was reformulated, Philadelphia pharmacy orders for 30-mg oxycodone pills had tripled.
“When they changed the formulation, people [in addiction] were switching,” said Devin Reaves, head of the Pennsylvania Harm-Reduction Coalition and in recovery from an opioid addiction himself.
But as their preferred pills became harder to find, many people turned to the city’s infamously cheap and potent heroin.
“All of a sudden, the illegal heroin was more regularly distributed on time, every day, easily accessible, and dependable than was the pharmaceutically made OxyContin,” said Philippe Bourgois, an anthropologist who studied drug markets in Kensington while based at the University of Pennsylvania.
People accustomed to carefully formulated pharmaceuticals can be especially vulnerable to overdosing on heroin and other street drugs, which are less predictable in their effects.
In the months after the OxyContin reformulation, heroin deaths increased nationally by about 25%, according to University of Pennsylvania economist Abby Alpert, who has studied the issue. In Philadelphia, people began fatally overdosing from heroin at double that rate.
Heroin overdoses increased by 77% from 2010 to 2011.
From the reformulation until March 2019, more than 5,300 people died of opioid overdoses in Philadelphia — 3,000 more deaths than would have occurred had death rates held steady.
A city survey showed that cost was the number-one reason that pill users started on heroin.
“Some switched to shooting heroin because it was cheaper to get,” Reaves said. “By 2014, 2015, I felt like everyone was switching to heroin.”
And with so many more people injecting drugs, the introduction of synthetic fentanyl into the heroin supply in those years proved especially deadly.
Representatives from Purdue declined to be interviewed on the record for this story.
Lawsuits against the company and Sacklers are frozen, pending approval of the current settlement and bankruptcy. Attorneys general from half of the states suing Purdue Pharma have not signed on to the settlement — Pennsylvania among them.
AG Shapiro hopes for a deeper share of Purdue’s profits from OxyContin. He called the proposed settlement a “slap in the face.”
The Inquirer’s investigative reporting is supported in part by the Lenfest Institute’s Investigative News Fund. Editorial content is created independently of the fund’s donors. A listing of Lenfest Institute donors can be found at lenfestinstitute.org. Gifts to support the Investigative News Fund can be made at www.inquirer.com/donate.