Richard Sackler got his wish, a new company to “take on the risk of new products.”1 Purdue Pharma Inc. incorporated in 1991, five years before it launched the successor to MS Contin. Raymond Sackler’s sons, Richard and Jonathan, as well as two of Mortimer’s daughters, Kathe and Ilene, became Purdue Pharma directors. Raymond’s wife, Beverly, and Mortimer’s third wife, Theresa, as well as another of Mortimer’s seven children, Mortimer Jr., joined the board a year before the company’s new drug went on sale.2
That oxycodone-based drug was still an unnamed product. Its first clinical trial had only been completed in 1989.3 Purdue would not even apply for a patent until 1992. The drug’s development was under the aegis of Purdue Frederick but only until it went on sale; it would then become a holding company.4 The marketing and sales meanwhile were split between Purdue Pharma Inc. and Purdue Pharma LP, another company the Sacklers created in 1990.5 They also incorporated PF Laboratories as the manufacturer. As for asset protection and tax mitigation, the family stuck to what the senior Sacklers had done since the 1960s and assigned key patents on the pills’ enhanced extended release coating to their Swiss-based Mundipharma AG.
Richard Sackler later admitted that while the corporate structure was indecipherable to outsiders, at times even he found it “confusing and complex.” Years later, in a deposition, he could not recall whether the directors of the many companies were the same or different.6 Nor was he certain whether sales representatives were employed by Purdue Frederick or Purdue Pharma.7 When asked, “How many Purdue entities are there?” he replied, “I don’t know.” He could not even provide a guess as to how many Sackler-owned companies existed.8 I 9
What was not in doubt was that a privately held and family-controlled drug company of Purdue’s size was increasingly rare.10 The pharmaceutical industry had been swept up in a mania of mergers and acquisitions that started the previous decade. There were $500 billion in deals over ten years. The Sacklers had watched with some envy as biotechnology companies only a fraction of Purdue’s size had successful public offerings on not much more than a dream encapsulated in a single product that existed only on paper. By the mid-1990s the largest ten firms accounted for half of all drug sales versus only 20 percent at the start of the consolidation.11
Only the large pharma conglomerates could afford research and development costs that had multiplied more than sixfold since the 1970s.12 Despite all the significant progress in chemistry and biology, it was still virtually impossible for scientists to be certain how a drug synthesized in the laboratory would react in people. Only about fifteen of every thousand lab compounds made it to clinical trials.13 After a GAO report found that nearly half the 209 drugs the FDA approved between 1976 and 1985 had caused serious and unexpected side effects, the agency set stricter guidelines.14 That meant human studies were more complex and expensive than ever. By the 1990s, each clinical trial for a mass-market drug included about five thousand subjects, more than double what had been required in the 1970s.15 Yet the success rate for the drugs that began those trials remained the same dismal 10 to 20 percent.16
Purdue had spent $40 million in developing and testing its MS Contin successor, which it had named OxyContin.17 While that was a fraction of what Big Pharma paid on major drugs, it was almost ten times more than the Sacklers had ever committed to a product.18 Richard Sackler kept assuring them it was a worthwhile investment.
OxyContin held the promise for all their dreams. In its November 1992 patent application, Purdue presented its drug as a breakthrough because a single dose lasted twelve hours to “control pain in approximately 90 percent of patients.”19 The emphasis on its twelve-hour duration was at the heart of Purdue’s strategy to set OxyContin apart from rivals. In pre-sales surveys, Purdue learned that patients with chronic pain rated as “very important” whether a treatment might require less frequent dosing. Its twelve-hour effectiveness was also the drug’s only tangible benefit on which Purdue could focus. Clinical trials had demonstrated that OxyContin did not have any therapeutic advantage over other opioid-based painkillers. The FDA later concluded in its review that OxyContin provided no better relief than immediate release generic oxycodone dispensed four times daily.20
Few outside of Purdue and the FDA knew that even the claim of twelve-hour pain relief had been cast into doubt in half a dozen clinical trials the company had sponsored. A third of the subjects needed another dose to offset pain before twelve hours expired.21 Under FDA regulations, however, only half of those in a trial had to get twelve hours of relief for the company to make the claim. About 55 percent of the trial subjects got the full relief Purdue promised.
In 1995, as the OxyContin application was pending at the FDA, Purdue geared up for what the Drug Enforcement Administration would later describe as “the most aggressive campaign for an opioid in U.S. history.”22 The Sacklers had opened up their checkbooks even before FDA approval to exert influence in the opioid and pain reevaluation movement. Purdue created a speakers bureau that attracted some of the leading pain management advocates, including two of the pioneers, Drs. Portenoy and Haddox.23 That speakers bureau was only a warm-up. Before and immediately after OxyContin’s 1996 release, Purdue spent millions on grants to patient/pain advocacy groups and sponsored over twenty thousand pain management educational programs. It subsidized dozens of conferences at which some five thousand doctors and pharmacists got all-expense-paid trips to listen to company representatives praise OxyContin as a “breakthrough painkiller.”24
One of Purdue’s most innovative ventures was creating special pain management curriculums at leading universities. It trained a future generation of physicians in the philosophy of “pain as the fifth vital sign” and that “not all opioids are bad.”25 At Tufts University, Purdue funded a master’s program titled “Pain, Research, Education and Policy” and was one of the biggest donors to the Tufts School of Medicine.26 An annual “Sackler Lecture” featured internationally renowned pain specialists. Tufts later appointed Richard Sackler a director of its medical school and when it gave his father, Raymond, an honorary degree, its president said, “It would be impossible to calculate how many lives you have saved.”27 At Massachusetts General, Harvard Medical School’s largest teaching hospital, the company spent millions on the Purdue Pharma Pain Program. It rolled out similar initiatives at Northeastern, Boston Universities, and the Massachusetts College of Pharmacy.
Purdue also spent money on medical associations that advocated for more liberalized dispensing of opioids.28 It provided 80 percent of the funding for the American Pain Foundation, a pain management organization of which Portenoy was a director.29 The University of Wisconsin’s Pain and Policies Studies Group depended on Purdue’s largesse.30 The company also wrote big checks to the American Pain Society and the American Academy of Pain Medicine. (A year after OxyContin’s release Purdue gave them $400,000, and through 2017 contributed an additional $2.1 million).31 II 32
Purdue, of course, was not the only pharmaceutical company with an opioid drug that dispensed money to the professional pain societies, as well as doctors and patient advocacy groups. Knoll Pharma (Vicodin), Ortho-McNeil (Tramadol), and Janssen Pharmaceuticals (Duragesic) provided about 40 percent of the associations’ annual budgets in the 1990s and more than a million dollars through promotions often disguised as public service education about pain.33
Beefing up the detail team was another pre-sales priority. Purdue doubled its sales force to six hundred before the drug launch.34 A good sales rep’s one-on-one pitch to a doctor was an unmatched way of creating a best-selling drug. The senior Sacklers knew firsthand that a detail team was indispensable. They recalled how in the 1950s, American Brands/Wyeth had knocked off Carter-Wallace’s number one selling tranquilizer, Miltown.35 The two companies marketed chemically identical drugs under different brand names. Although Miltown had the advantage of being first on the market, Carter-Wallace could not maintain the sales momentum since it had no detail team. American Brands, on the other hand, had its 1,500 salesmen saturate the country.36 The success of American Brands sparked a boom in detail teams. Into the 1970s the drug industry spent twice as much on promotion and marketing as it did on research and development.37
There was another benefit to one-on-one pitches. Since there was no record of what was said in the doctor’s office it was impossible for competitors or government regulators to determine if the salesmen adhered to the efficacy limits the FDA had set for the drug or provided adequate warning about side effects. Sales representatives were careful not to leave notes at the doctor’s office. Purdue’s internal documents reveal that management constantly reinforced to the detail squad that they “commit nothing to a permanent record.” Anyone making such a mistake would be subject to “immediate dismissal.”38
In March 1995, the sales and marketing divisions gathered at the company’s Norwalk headquarters to strategize about how to best promote OxyContin.39 First, they were told, it was not simply MS Contin version 2.0. “We do not want to niche OxyContin for cancer pain,” a marketing executive said in leading off the presentation.40 They had to generate enthusiasm about the drug. That required marketing it as the industry’s long-awaited miracle pain reliever, a narcotic analgesic with longer-lasting benefits and fewer risks than any predecessor.
Purdue had discovered in focus groups that general practitioners still balked at dispensing opioids for anything other than end-of-life pain. An independent study showed many were reluctant even then. Half the patients who died in hospitals received no pain medication during their final week. Another report showed that only a quarter of elderly cancer patients in nursing homes were given any medication.41 That opioid-based painkillers were not being used even in hospitals and nursing homes served as a sharp reminder to the sales team of the challenge they faced. It was disappointing that despite a decade of the pain and drug reevaluation movement many doctors stubbornly clung to what the Sacklers thought were outdated views of pain and the risks of addiction from opioids.
Since it was not possible to dodge the issue, Purdue reps were instructed to raise “concerns about addiction” before the physician did.42 Patients developed “a normal physiologic response [but] tolerance and physical dependence [were] not the same as addiction.”43 That only happened, they said, when “a susceptible individual” got the drug and ignored the doctor’s dosing instructions.44 It was understandable that no matter how wonderful a drug, “a small minority” of patients “may not be reliable or trustworthy” for narcotic painkillers.45 If the doctors remained skeptical, the detail team was to show them the drug’s FDA-approved label that stated if OxyContin was used as prescribed for treating moderate to serious pain, addiction was “very rare.”46
To emphasize the point, flashy charts prepared for the sales team illustrated how each pill released oxycodone into the bloodstream at a steady rate over twelve hours. That gave the sales reps a chance to tout OxyContin’s patented, controlled release coating, an improved version of the one that worked so well with MS Contin. That coating, Purdue claimed, made it impossible for addicts to get the rush they chased. Without a high, patients would not want more of the drug as it wore off. Those charts would prove to be powerful aids that bolstered the company’s claim that there was little chance of OxyContin abuse.47 The odds of addiction were “much less than one percent,” the detail squad hammered, so long as the “pain patients are treated by doctors.”48 III 49 One of Purdue’s cleverest marketing lines was that OxyContin provided “relief—not a ‘high’… [when] taken as directed.”50
There was a problem with those charts, however, that would remain a Purdue secret for nearly a decade: the data downplaying the odds of addiction had been skewed.51 Worse, the company approved it although its own clinical trials demonstrated that for some patients up to 40 percent of oxycodone was released into the bloodstream in the first hour or two.52 That was fast enough to cause a high, and for some resulted in a crash that required another pill to feel better.
To tilt the odds in favor of its “low risk of addiction” sales strategy, Purdue later underwrote several studies that reported addiction rates from long-term opioid treatment between only 0.2 percent and 3.27 percent. Rigorous independent studies never confirmed them. It was not rare in the drug industry for a company-sponsored study to return a result that echoed the marketing. A review of a thousand clinical trials over ten years among many different classes of drugs reveals that pharma-funded studies produced favorable results far more often than government-sponsored trials. Depending on the drugs and years, the pharma-subsidized trials produced positive results about a minimum of 50 percent more frequently and for some drugs an eye-popping twenty times more often.53 Those results explain why clinical studies paid for by drug companies, which were only a quarter of all trials in the 1980s, were more than half by the late 1990s.54 And it explains why Purdue financed its own to obtain the right “risk of addiction” numbers so the sales team could tell doctors that “Oxy was non-habit forming.”55 Even as late as 2019, a former Purdue director, Richard’s son, David, when asked in an interview about OxyContin’s addiction rate, cited a 2018 study in the British Journal of Anaesthesia that put it at 4.7 percent. “I think a fair number is somewhere between 2 and 3 percent.”56
The author learned there was at least one later instance in which a Purdue employee at the Stamford headquarters asked whether it was possible the studies had a flawed methodology that led to the underestimating the real-world opioid addiction rate. A division manager closed off any discussion; that question reflected a defeatist attitude, he said, and would not be tolerated.57 IV 58
After OxyContin’s release, Purdue got help in promoting the “low risk of addiction” from the American Academy of Pain Medicine and the American Pain Society.59 Both were beneficiaries of generous funding and subsidies from Purdue and other opioid drug manufacturers.60 They issued a consensus statement emphasizing that opioids were effective for treating nonmalignant chronic pain and reiterating that it was “established” that there was “less than 1 percent” probability of addiction.”61 Purdue had developed its own simplified pain rating scale, a sheet of facial expressions ranging from smiling and happy to frowning and sad. It distributed tens of thousands to physicians.62 Allowing a patient to leave a medical appointment with untreated pain, Purdue sales representatives told doctors, bordered on negligence.
In order for the detail team to concentrate on those physicians likely to write the most prescriptions, Purdue went to IMS (International Marketing Service). Advances in computers and software had changed medical data collection in the near forty years since Bill Frohlich and Arthur Sackler had founded IMS.63 Instead of manually entering data obtained from those pharmacists willing to share it for a small fee, “information technology” allowed IMS and its rivals to collect virtually all prescription information from pharmacies and hospitals. The American Medical Association, representing more than half the nation’s physicians, cooperated by licensing the dispensing information in its “Physician Masterfile.”64
Initially Purdue only bought lists of doctors, sorted by zip code, who were heavy prescribers of existing painkillers such as Vicodin, Percocet, Lortab, and Percodan.65 Those records covered about 5,000 of the country’s 800,000 active physicians.66 According to the charges set forth later in a complaint by the Massachusetts attorney general, that was enough for the sales squad to focus on what Purdue internally dubbed the “core dispensers,” the physicians it believed “could be influenced to increase opioid prescriptions the most.”67 The author discovered that Purdue later spent more than a million dollars to buy IMS’s Cornerstone 3.0 software. It was the only system then capable of providing the sales team real-time updates on prescriptions written by doctors in their sales territory.68 That software “put the sales department on steroids,” recalled an assistant marketing manager.69
Purdue did not expect its detail team to make a generic pitch to doctors for more liberal dispensing. The marketing team had targeted specific patient groups in the hope of tapping into a much wider market than the one for MS Contin. Geriatrics topped the list. Sales reps told doctors that OxyContin improved “the quality of life” for seniors. They played off the phrase “performance enhancing drugs” that described anabolic steroids used by athletes, to suggest that Oxy could “enhance personal performance.”70 There were no studies that supported their “quality of life” or “personal performance” claims. And they did not mention those studies that showed patients older than sixty-five on opioid painkillers had increased risks for falls and bone fractures.71
A second part of the geriatric strategy was pushing Oxy for an indication not approved by the FDA, osteoarthritis. Purdue had tested OxyContin for it and failed to find any benefit. Why misrepresent it as effective in relieving arthritic pain? It is the most common age-related disease, affecting more than 80 percent of those older than fifty-five. And the last element in the geriatric sales strategy was to focus on nursing homes and long-term-care facilities. Purdue thought it possible to “maximize demand” there since they were essentially “open formularies” (they have few limitations on access to medicines).72
Veterans were the next priority. Purdue had accumulated a file of anecdotal evidence that chronic pain was one of the most common complaints at VA hospitals. The Department of Veterans Affairs later released figures that confirmed that 60 percent of vets returning from Afghanistan and Iraq suffered from chronic pain. Fifty percent of veterans from previous deployments had the same complaint. Purdue created separate publications and pamphlets for vets and later contracted with a decorated combat veteran for a book that urged veterans returning from combat zones to ask their physicians for opioids and lobby hesitant prescribers. Opioids were not addictive, claimed the book, unless someone was “predisposed” because substance abuse ran in their family.73
The author learned that there was some discussion inside Purdue that the high rate among returning veterans of substance abuse (estimated at 20 percent) might make them more vulnerable to OxyContin addiction.74 While the focus on veterans later paid off financially for Purdue, it did translate into an addiction rate for veterans much higher than other OxyContin patients. And ultimately, they were twice as likely as the national average to die of a drug overdose.
Aside from geriatrics and veterans, Purdue had a catchall category, those who had never tried opioids. Marketing dubbed them “opioid naive.” The detail team called them OVS (opioid virgins). It was a huge market. Purdue was prepared to distribute hundreds of thousands of brochures that suggested OxyContin could treat many different conditions (none of them expressly approved by the FDA). One of its most popular was “How You Can Be a Partner Against Pain and Gain Control Over Your Own Pain.” It suggested that patients discuss with their physicians if OxyContin was the right remedy for backaches, migraines, sore knees, even tooth extractions.
The second-generation Sackler directors knew that the detail team’s success could make or break the drug. That did not mean, however, that they planned to rely only on direct sales. Purdue authorized the development of modern promotion strategies to coincide with the launch. OxyContin Physicians Television Network was an online video service in which paid medical consultants hyped the drug.75 Purdue set aside a budget large enough for dispatching hundreds of physicians across the country encouraging their medical colleagues to learn about the advantages of dispensing OxyContin for chronic pain. It also funded half-day courses aimed at general practitioners. Purdue needed them to write a lot of OxyContin prescriptions if the drug was to become a blockbuster.76
Online promotion was also a priority. One website, In the Face of Pain, targeted health care professionals looking for information about pain treatment. The content was presented as unbiased professional testimonials, but Purdue did not disclose that it had paid $250,000 to the eleven featured “advocates.”77 Another website, Partners Against Pain, conducted a poll of a thousand chronic pain sufferers. A third of the respondents ranked their pain as “debilitating” while 15 percent said it was so unbearable that they had contemplated suicide.78 Partners Against Pain was where Purdue mastered the art of disguising straightforward public relations as a public service about pain management. The company’s Pain Assessment Scale was the site’s most visited page. Another page claimed that pure opioid agonists such as oxycodone, morphine, heroin, or fentanyl had “no ceiling dose.”79 That meant that a patient in severe pain will always get additional relief from higher doses of opioid painkillers; there is no analgesic ceiling.80 The downside at those high doses is an increased possibility of death since the opioids suppress the respiratory system.81 Purdue did not list that on Partners Against Pain and internal company files reveal it realized consumers were likely to misinterpret “no ceiling dose” to mean that opioids were safe at high doses.82 (It eventually spent $8 million subsidizing Partners Against Pain.)V83
As the date approached for OxyContin to go on sale, Purdue moved its promotion campaign into high gear. Some of the strategies were old-school ones developed by Arthur decades earlier and that had since become standard for drug companies rolling out highly anticipated medications. They included slick brochures, newsletters, magazine inserts, flashy mailings to doctors, big ad spreads in medical journals, and sponsored programs at medical schools. The detail team got ready to distribute millions of dollars in Oxy-branded swag to doctors, pain clinics, hospitals, and nursing homes in their sales territories. There was everything from luggage tags to baseball caps and sweatshirts, notepads, binders and pens, coffee mugs with heat-activated sensors, even stuffed toys for children. Two favorites, for which Purdue had to place reorders repeatedly, was a pedometer stamped: “OxyContin—A Step in the Right Direction,” and a CD, “Swing in the Right Direction with OxyContin,” in which a couple danced over a giant Oxy logo.84 VI 85
All that money was well spent. A later study in New York State demonstrated that for every dollar in promotional goods, entertainment, or travel that a doctor received “he or she prescribes at least $10 of additional opioids.” Purdue expected that the more they spent and lavished on high-prescribing doctors, the greater the return on their money. That proved to be right beyond the most optimistic internal forecasts. The New York study showed that the “top 1 percent of Oxy prescribing doctors got 80 percent of the money paid by Purdue.”86 A study published in JAMA later showed that even something as simple as buying a meal for a doctor resulted in increased opioid prescribing.87
A week before OxyContin went on sale, Russell Portenoy and Dr. Ronald Kanner published a 357-page book titled Pain Management: Theory and Practice.88 Purdue had been expecting it. A dozen well-known physicians, in specialties from rheumatology, anesthesia, behavioral medicine, surgery, psychiatry, and rehabilitation, contributed to what became recognized as the definitive guide to the latest research about diagnosing pain and how to treat it. Opioids, they concluded, were unfairly pilloried because of their “association with drug abuse.”89 Citing 176 studies and journal articles to support their thesis, Portenoy and Kanner methodically dismissed concerns about long-term opioid use. “Misconceptions about tolerance and dependence are common and reflect the stigma associated with opioid drugs.”90
While Portenoy and Kanner admitted there were “unfortunately, no systematic studies of the addiction liability associated with the long-term medical use of opioid drugs,” they were confident their review of “the evidence suggests that the risk of addiction is extremely low in the typical patient with no prior history of drug abuse who is prescribed an opioid for a painful medical condition.”91 VII 92
The American Pain Society followed the Portenoy and Kanner book with a pamphlet, “Treatment of Pain at the End of Life.” It drew the startling conclusion that distressed patients would not turn as frequently to suicide if opioid painkillers were dispensed more freely.93
I. Mortimer and Raymond followed Arthur’s playbook and incorporated multiple Purdue-named entities during several years before and after OxyContin’s release. The author located nearly seventy post-1990 “Purdue Pharma” companies, most concentrated in the Northeast. In Delaware, there were twenty-six Purdue-named companies, sixteen in Connecticut, and another five in New York. An additional Arthur-inspired strategy was using similar company names. In half a dozen instances, the only difference were the letters at the end of the name indicating its legal status, as with three separate Purdue Neuroscience companies, one a Corp., another an Inc., and the third an LP. The same business addresses often overlapped for some, including Purdue AO Pharmaceuticals Inc., Purdue Biopharma, Purdue Healthcare Tech, Purdue Pharma Manufacturing Inc., Purdue Associates, Purdue Land, and Purdue Products.
II. The heavy spending not only continued but increased until 2016 when it dropped for the first time. From 2013 through 2017, Purdue spent $49 million on doctors and a broadly defined category “Research Payments,” the latter comprising mostly grants to teaching hospitals. The author calculated that about 70 percent of those funds were directly for promoting OxyContin, and more than 95 percent for Purdue’s stable of opioid-based drugs. The payments to doctors were primarily consulting fees, but also included approximately $3 million for “food and beverage,” another $900,000 for speaking fees, and $750,000 for “travel and lodging.”
Purdue’s $49 million was a small part of the industry’s overall $9 billion spent on 900,000 doctors over the same time. Details on the the promotion money paid by pharmaceutical companies, broken down by specific drugs, became public in August 2013, as required by the Affordable Care Act (it was included in a provision of the statute aptly titled “Physician Payments Sunshine Act”). The federal government’s Centers for Medicare and Medicaid Services has compiled huge raw data information files for public review (https://openpaymentsdata.cms.gov), and ProPublica has entered it into a single searchable database. Also, there is public information about payments from 2009 to 2013 for seventeen drug companies that were required to disclose it as a result of litigation settlements. Those companies represented about half the drug sales in the U.S. Purdue was not one of them.
III. No one was aware that Arthur had drawn the opposite conclusion about the addictiveness of narcotic painkillers. The author discovered 1966’s The Anatomy of Sleep, a 135-page book about the physiology and pharmacology of sleep. Arthur helped Roche Laboratories prepare the book. It was designed to subtly promote Librium and Valium as useful sleep aids, although the FDA had not approved them for that purpose. In discussing other pharmaceutical aids, it stated: “If sleeplessness is pain-related… primarily, narcotics are prescribed for relief of pain.… The addiction potential of narcotics is well recognized in our century, as it was not always in the past.”
IV. That concern later turned out to be right. All the studies had excluded patients with preexisting mental health disorders or previous substance abuse. Those were the very patients who were far more likely to develop addiction problems. Later studies that included those patients also followed them over a year or more of outpatient treatment. The reported addiction rates in those studies ranged from a low of 32 percent to as high as 80 percent.
V. Software programmers added a feature to Partners Against Pain that made it easier for patients to find a local “pain specialist.” Referrals were provided based on the patient’s address. What the patients did not know was that the website was coded to display the contact information only for doctors who were heavy prescribers of narcotic painkillers (information Purdue knew from its IMS data files). Before OxyContin’s release, Purdue had compiled a database of tens of thousands of patients who were searching for pain specialists. That became part of a special promotion file Purdue aggressively utilized once the pill was on sale.
VI. Some gifts by sales reps in other drug companies became the examples of what not to do. A Pfizer detail man once paid a doctor an “unrestricted educational grant” of $35,000. Both knew it was so the doctor, a top prescriber, could build a swimming pool in his backyard. The larger debate was whether doctors were unduly influenced by modest drug company gifts. Studies reveal that physicians who accept perks and gifts are more likely to write prescriptions for that company. That is a statistical coincidence, claim defenders of the gifts policy. Bert Spilker, a senior VP of the drug industry trade group PhRMA, wrote in an editorial in Health Affairs, “I find it hard to imagine that any of my colleagues would compromise professional concern for their patients… [by] ‘selling their souls’ for a pack of M&M candies and a few sandwiches and doughnuts.” Social scientists who have studied drug detail teams believe that even when the gifts are modest, they create a subconscious sense of debt for the physician, one they repay by writing more prescriptions for the sales rep’s drug.
VII. Portenoy and Kanner explained away one study that reported a high addiction rate of 19 percent. They contended it was from a pain management program in which many patients had “a prior history of drug abuse, personality disorder, younger age, and chaotic family life.”