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Does the TV series "Dopesick" make some doctors look gullible or greedy, easily swayed to prescribe opioids by the lure of pharma swag and all-paid trips to posh golf resorts?

Does it portray federal medical officers in charge of ensuring the safety of the nation's prescription medicines as willing to approve Purdue Pharma's favored label language -- that OxyContin's delayed absorption reduces the risk of abuse despite no evidence -- because it would lead to a six-figure job with the industry?

Are many physicians depicted as making millions running pill-mill clinics, where drug seekers line up for blocks to obtain hundreds of prescriptions at higher and higher doses, with many receiving no physical exam?

Yes, kinda, to all of the above. In many ways, the show does not put physicians in the best light. They aren't drawn as critical thinkers asking hard questions -- like how can an opioid be prescribed for pain as mild as headaches or hangovers without terrible consequences? How is it not addictive?

But that doesn't mean doctors shouldn't watch the show, said Andrew Kolodny, MD, medical director of the Opioid Policy Research Collaborative at Brandeis University in Waltham, Massachusetts, who also was a medical advisor for the show.

Public Health Catastrophe

"I think doctors should watch this series because it carries important lessons for doctors about how pharmaceutical marketing can result in a public health catastrophe," Kolodny said. To this day, doctors continue to be targeted by pharmaceutical marketing strategies, including data gathering on their prescribing practices, he said.

"Our patients ultimately pay the price for the influence that drug companies have," Kolodny said.

Kolodny values the industry's "ability to find cures and treatments. But there needs to be much better firewalls so that drug and device manufacturers don't have undue influence on medical practice," as the show so clearly depicts.

While opioid prescribing has fallen in recent years, "there is still no other country that comes close to prescribing as much opioids as we do," he said.

The series of eight episodes -- the last of which -- is based on the nonfiction book, Dopesick: Dealers, Doctors and the Drug Company that Addicted America by Beth Macy.

The show wraps around a fictional Dr. Samuel Finnix, played by Michael Keaton, a widower practicing in an Appalachian coal mining town where workers are frequently injured but often go to work enduring terrible pain. He's a kind, caring doctor who makes house calls, even just to make sure a patient remembers to take her medication.

A young, ambitious sales rep from Purdue looking to make a lot of money sweet-talks his way into Finnix's practice with flowers and fried chicken, and mani-pedis for his nurse. He wants Finnix to prescribe a new opioid drug that can relieve patients' chronic pain. Best of all, he said echoing the Purdue mantra, "less than 1% become addicted."

Hangovers and Headaches

"Backaches, toothaches, headaches, joint discomfort, arthritis, hangovers, the possibilities are endless," a Purdue official is shown coaching his sales team assigned to target Southwestern Virginia, Eastern Kentucky, and rural Maine, people in mining and logging centers who get injured on the job.

"These people are in pain. They have hard lives, and we have the cure. So we are sending you all into the wild to flip these country doctors from Percocet and Vicodin to OxyContin," the official tells the team. "Make your doctors feel special. Take them to expensive dinners."

But all too many of Finnix's patients do become addicted, including himself after he doubles and redoubles his doses to relieve pain from an injury he endured when a car hit his truck.

Like many of his patients, he goes downhill fast, eventually taking OxyContin from his own patients, ultimately buying from street dealers. He learns he can snort the drug to get a bigger effect.

After he botches a procedure and loses his medical license, he enters rehab. But even there, he craves the drug so much, he asks the Purdue rep to visit him in treatment only to ask him, "Do you think you can get me some pills?"

Though Keaton's character is fictitious, real doctors are depicted by name as well. An actor portrays Russell Portenoy, MD, a highly respected New York pain specialist, telling thousands of physicians who assembled at a lavish Purdue conference that they should not hesitate to prescribe OxyContin for chronic pain.

Adriane Fugh-Berman, MD, professor of pharmacology and physiology at Georgetown University in Washington, D.C., and director of PharmedOut, also thought parts of the series contained good lessons for doctors, although she prefers they read books that don't fictionalize the events -- Barry Meier's Pain Killer: An Empire of Deceit and the Origin of America's Opioid Epidemic, and Macy's Dopesick.

FDA's Revolving Door

One of those lessons is the recognition that still, "there is a revolving door between FDA and pharma," which begs the question, "Are there other officers at the FDA who are auditioning for jobs in pharma that could be an issue?" Fugh-Berman said.

She was speaking of Curtis Wright, MD, whose character is represented in the show. Wright was the FDA chief review officer who oversaw approval of the label advising physicians on use of OxyContin, as Purdue officials requested. The wording said OxyContin "is believed to reduce the abuse liability of the drug." A bit more than a year later, the real Wright took a job at Purdue at a salary of $379,000.

"We don't want FDA staffers making industry-friendly decisions that are against public health or are against the principles the FDA should be operating under," Fugh-Berman said. And, she said, 13% of OxyContin users became addicted -- not fewer than 1%.

Physicians may see themselves portrayed in the show as more trusting than most, she continued. "Many principles of social psychology are used by companies to manipulate physicians emotionally, and they work just as well or better than manipulating other people emotionally," she said.

Bottom line: Opioid marketing isn't in the past. "It's still going on, and we have documented messages that go against science," said Fugh-Berman.

Another real person and star villain in the show is Richard Sackler, MD, played by actor Michael Stuhlbarg. Sackler's family owns Purdue and he is on a mission to beef up the company's profits by making OxyContin "the first billion-dollar drug" and the "greatest painkiller in the history of human civilization."

Born to Be Addicted

When it became apparent that thousands were overdosing and dying, Sackler is depicted as insisting, "This is not our fault. These people want to be addicted." They are born abusers, he said.

Fugh-Berman said that portrayal of Sackler is not only an accurate depiction, but that the strategy to "blame the addicts, they are the culprits" is still a belief in some specialty organizations that insist legitimate pain patients do not get addicted, "and that's not true."

Prescribers' gullibility and trust in what sales representatives were telling them is laced throughout the show.

For example, Purdue's claim that a New England Journal of Medicine study showed the drug to be non-addictive was based on a lie, prompting one to wonder why more physicians didn't see through it.

In fact, what Purdue referenced was not a study, but a five-sentence from Hershel Jick, MD, of the Boston Collaborative Drug Surveillance Program. It was based on patients who took hydromorphone, Percodan, and meperidine, not OxyContin.

Physicians may feel embarrassed after seeing how easily their colleagues were deceived in a number of other ways. For example, Purdue produced a chart showing patients' blood levels did not have spikes and drops as would be expected with opioids. But the chart's axis was compressed in a way that was, a scientist tells federal investigators, "absolutely deceptive" because when shown correctly, the chart clearly showed dramatic spikes and drops.

But they shouldn't feel embarrassed, Kolodny said. "You have to recognize that doctors were hearing from every direction that we had been under-prescribing opioids because of overblown fear of addiction, and that patients were suffering needlessly."

The Fifth Vital Sign

Doctors were hearing that message from state medical boards, from professional societies, from hospitals and pain specialists eminent in their fields. They were hearing it from "grassroots patient organizations" created by the pharmaceutical industry as well as from the popular press, Kolodny said.

"If from every direction you're hearing you should be prescribing more opioids, and that patients with legitimate pain don't get addicted, it would have been very hard not to be swayed," he said.

Kevin Zacharoff, MD, pain and addiction specialist at Stony Brook University in New York, said he hopes doctors who see the series will realize that information "probably isn't best if it's coming from a pharmaceutical company that is trying to basically do one single thing: sell more product."

The show's message also highlights a problem increasingly recognized as overdose deaths and hospitalizations continue to horrify families and burden healthcare institutions: Most doctors don't get any education about treating pain in medical school, nor in family practice residency. Finnix "was forced to learn as he went," Zacharoff said.

The show also takes on most of the pain societies as examples of how pharmaceutical company-funded education that's supposed to be non-promotional actually is very promotional, he said. The firewall that's supposed to be in place has "leakage."

"What the show was trying to portray when it showed the American Pain Society logo and the American Pain Foundation logo, and others, is that if there's money moving, basically there's messaging happening. That's something that could resonate with clinicians who watch this show," Zacharoff said. Both organizations are now defunct.

Macy, the author of the book the show is based on, told 番茄社区 in an email via a spokesperson that the show definitely has messages for physicians. Doctors, she said, "played a role in the creation of this iatrogenic epidemic and they should play a role in helping to get the 2 million-plus Americans with opioid use disorder out of it."

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