I should give a little context: I rarely prescribe opioids to opioid-naive patients — a more common scenario is patients who are already on a regimen that I then continue when they come into the hospital. And certainly not all opioids are the same, and some have less abuse potential, etc.

But it’s a good question. I feel the miscreance is often unrelated to whether there is value, simply because of the widespread nature of miscreance in drug and device marketing. And I do think the drugs in question have some value. I don’t know about Subsys in particular, but its FDA-approved indication, breakthrough cancer pain, is unfortunately quite real and quite horrible, and not fully understood as to why it doesn’t act like “normal” pain and respond to “normal” therapy the same way.

I think the challenge (and the concern) for me is that — in the U.S. at least — the drug you take, the artificial knee you have implanted, even the suture you get stitched up with — these are all sold to doctors with varying levels of aggression on the part of the manufacturers, because the doctor is the decision-maker and his/her buy-in is worth everything. (Thus, “Ask your doctor about...”) It doesn’t necessarily mean the drugs or devices or therapies aren’t the right choice... it just means doctors have this bizarre other force (money) to contend with in our decision-making. And subconsciously or consciously or (worst of all!) in bad conscience, as in this article, doctors choose the drugs they prescribe because they’ve been marketed to.

It seems you are implying the parent comment is hypocritical. Unfortunately, the current reality we live in means complicity isn't necessarily a choice. The whistleblower is always a part of the machine he is exposing.

I’m trying to figure out whether Purdue Pharmaceuticals is unalloyed evil or whether they are defensible.

People do have legitimate chronic and/or acute pain, often severe. So there's a need for the painkillers in the market.

The problem is that Purdue's marketing went way beyond what was justified, leading to widespread overprescribing where that strength of painkiller wasn't necessary.

Neither?

I don't even know how it is possible for a corporation to be 'unalloyed evil'. At least above some threshold size, you're going to mishire and get someone who fails to kick all the puppies or twirls their mustache at an inappropriate time.

More seriously, strong drugs with high addiction potential are medically necessary for those who need them (my understanding is that there are no substitutes in some situations, and a lot of the substitutes for other situations are substantially worse along some dimensions). That shouldn't mean you do whatever you can to push volume, but, well.

So, in my view, they're producing important product. They're also run by awful, greedy human beings who should be snubbed by non-awful humans.

It is just another reminder that win-at-all-costs capitalism has... costs.

(If true as reported that...)

Given that they knew that their formula didn't last for 12 hours, and their response to each doctor was "increase the dosage and keep the 12 hour interval" which of course means a greater risk of addiction, I'd go with unalloyed evil.

It isn't binary. Neither is there a binary choice between ending the company, and letting them do whatever.

One issue is how drug reps push off-label prescribing. In order to increase sales. That was the core issue with Neuronin (gabapentin), for example.

Although off-label marketing is inappropriate and possibly illegal, in this case I believe patients probably benefited from it.

Off label prescribing is perfectly legal; off label marketing, however, is illegal.