Pubdate: Mon, 18 Aug 2003
Source: Kansas City Star (MO)
Copyright: 2003 The Kansas City Star
Contact:  http://www.kcstar.com/
Details: http://www.mapinc.org/media/221
Author: Charles B. Camp, Lexington Herald-Leader
Bookmark: http://www.mapinc.org/oxycontin.htm (Oxycontin/Oxycodone)

INSIDE A PAINKILLER'S SALES PITCH

As abuse grew, an OxyContin rep found himself trying to calm doctors' fears

HAMILTON, Ohio - As OxyContin abuse became big news in 2001, Dr. Ghassan
Haj-Hamed grew increasingly concerned.

Colleagues were giving him grief over the amount of the potent painkiller he
was prescribing, he told OxyContin salesman Shane Foster over lunch in early
February.

Foster reassured Haj-Hamed, a top client, "that he was doing the right
thing," according to a memo the salesman wrote afterward.

But Haj-Hamed was actually doing wrong, a federal agent would later say.

Even as the two talked that dreary afternoon in Cincinnati, law officers in
Northern Kentucky were focusing on the doctor as a major source of illegal
OxyContin and other prescription drugs in the region, according to a federal
agent's affidavit filed in a Cincinnati court.

Today, Haj-Hamed's Kentucky and Ohio medical licenses are suspended, and
liens have been placed on about $1 million worth of property by federal
prosecutors, who are investigating his prescribing practices.

Haj-Hamed says that he is innocent and that he expects to get his licenses
and property back.

But his problems illustrate the tightrope that Purdue Pharma, the maker of
OxyContin, walked as it pushed sales ever higher in the face of a worsening
abuse crisis.

Drug regulators, law officers, addiction experts and others have contended
that Purdue oversold OxyContin right from the start in 1996, causing an
oversupply that spilled into illegal markets. Purdue has vigorously denied
that claim.

But although the company's advertising and promotional materials are subject
to regulatory scrutiny, there's no oversight of what its hundreds of sales
representatives said to the thousands of doctors they met repeatedly,
one-on-one, in those years.

Now a glimpse of how one OxyContin rep built and protected his piece of the
market has emerged from a little-noticed lawsuit pending against Purdue in
Butler County, Ohio.

The case file contains "call notes" that Shane Foster wrote after seeing
doctors -- notes that contain reminders such as "needs to be pushed to use
more" and "remember to always sell."

Foster also wrote of trying to calm worried pharmacists, some of whom were
contacting regulators with fears about doctors' OxyContin prescriptions.

And he wrote over and over of reassuring doctors such as Haj-Hamed to "do
the right thing" and continue prescribing the pills.

Foster, whose territory borders Cincinnati, did not return messages seeking
comment. Robin Hogen, Purdue's vice president for public affairs based in
Connecticut, said it would violate corporate policy for Foster to talk to
the news media and that he could lose his job if he did. Saying that he was
speaking for the salesman, Hogen called Foster's actions appropriate.

In a 151-page deposition he gave in the lawsuit, Foster depicted his job as
more missionary than mercenary; he spoke of giving "some dignity in life
back" to people who suffer chronic pain.

He described himself as a facilitator for health-care professionals who were
fighting a tide of untreated misery.

"I want them to use any pain agent. And if they can use OxyContin, great,"
he testified.

Foster began working for Purdue in late 1998, bringing a degree in nursing
and eight years' experience at three top drug companies.

In 2000, sales in his territory north of Cincinnati nearly doubled, and he
earned about $140,000, some $90,000 of it bonus pay.

Foster, who is not a defendant in the case, has been summoned as a witness
because he "typifies the entire marketing scheme" that Purdue and a
contractor used, said Scott Frederick, a Hamilton lawyer who represents
people who claim they were harmed by the drug.

The suit claims that Purdue and Abbott Laboratories, the giant drug company
Purdue hired to help sell OxyContin, played down the drug's risks, causing
many Ohio residents to become dependent on pills they didn't want or need.

"Corporate pushing," Frederick called it last year during a hearing after
which the case became the only certified OxyContin class action in the
country.

Purdue and Abbott say that many of their sales strategies are distorted or
misrepresented in the suit.

Doctor under suspicion

In February and March 2001, after their lunch together, Foster dropped by to
steady Haj-Hamed three more times, the salesman's notes show.

At the same time, according to the federal affidavit, the FBI quietly began
investigating the doctor's activities at a Bellevue clinic, one of four in
Kentucky and two in Ohio with which he was affiliated. By year's end, agents
were conducting an extensive undercover operation at another office in
Falmouth, the affidavit shows.

Last Sept. 25, Pendleton County deputies stopped Haj-Hamed's car outside of
Falmouth and arrested him on numerous state charges of prescribing drugs
without a lawful purpose. The license suspensions in Kentucky and Ohio
followed, as did a civil lawsuit by a Campbell County woman who claims
Haj-Hamed contributed to the drug-related death of her sister last October.

In an interview, the doctor said his arrest wasn't legitimate because agents
lied and faked pain to trick him into prescribing pills. A state prosecutor
dropped those charges in March, saying federal authorities had asserted
jurisdiction over the case. Their investigation is still open, said
Haj-Hamed's lawyer, Robert Blau of Cold Spring. He predicted his client
would be cleared.

The wrongful death suit is baseless, Haj-Hamed said. And he said he's
fighting the Kentucky medical board in administrative and court proceedings.
Ohio's suspension is based on Kentucky's action.

Haj-Hamed expressed no regrets about prescribing OxyContin to his patients
or about the drug salesman who encouraged him to do so. Foster "was always
fair and honest" and produced documents to back up his promotion of the
drug, Haj-Hamed said.

It's unclear whether Foster got sales credit for the Cincinnati doctor's
Kentucky prescriptions. There's no evidence that he knew that Haj-Hamed was
under investigation.

But it's clear that he knew the doctor was a busy prescriber of pain
medicines.

'Get him to help push more Oxy'

In working his territory, Foster used company-supplied reports that showed
the amounts of various pain drugs prescribed by each doctor on his list.

One such printout in the court file for early 2001 named 115 "A-1"
candidates. The top prescriber of all types of painkillers was Haj-Hamed,
who averaged an estimated 800 prescriptions a month; the No. 2 doctor wrote
about 500.

Foster called on Haj-Hamed a dozen times in a six-month period. He visited
another doctor, who ran two offices, 44 times, the printout showed.

Hastily written notes from some of his calls on those and other doctors
suggest a consistent message: Treat more patients with OxyContin, do it
earlier in the process, and stick to your guns once you do.

In March 2000, Foster dashed off this reminder for his next call on one
doctor: "keep him writing more." Two weeks later after a return visit, he
wrote, "expand use." Two days after that, "set plan for high use."

He told himself to get some doctors to "use sooner" or "dose higher." He
concluded that one physician "needs to be pushed to use more and reminded
more often."

Foster translated many of those comments in his deposition.

Expand use? "Yeah, I'd like him to help people that are in pain." Use
sooner? Switch to OxyContin instead of piling on other pills with
ingredients that cause side effects. Dose higher? Use one bigger OxyContin
tablet instead of two smaller ones.

As for the doctor who "needs to be pushed," Foster said, "I wanted her to
realize that OxyContin was an equal choice" to taking several rival pills a
day.

But at one point, he let his words stand.

"Get him to help push even more Oxy," he wrote after leaving one doctor's
office. When questioned about that memo, Foster simply replied, "Yep," and
"That's what I wrote."

Hogen, Purdue's public affairs executive, said the use of the word "push"
was "unfortunate," and said that the sales rep probably meant, "I need to
work harder" to help the doctor help his patients.

Foster's call-note comments are "shorthand -- the vernacular of a salesman"
and shouldn't be over-interpreted, Hogen said. Purdue lawyers have also
objected to their use in court, labeling them "snippets of notes selectively
culled" from his files.

Damage control

In April 2001, a week after news broke that the Butler County sheriff had
charged a dozen people with OxyContin abuse and trafficking, one of Foster's
leading prescribers began to doubt himself, the notes show.

The doctor "threatened to not write anymore," Foster wrote. "Make sure he
does not do that," he reminded himself.

In his deposition, Foster later said that the doctor had just been thinking
aloud. He said he told the physician to go by "what he knows is right and
not what he reads in the paper."

The call notes show that the salesman also wrestled repeatedly with what he
short-handed as "pharm issues" or a "pharm problem" -- matters involving
local pharmacies.

He visited one pharmacist whom he suspected of "turning in" a doctor to
state regulators over OxyContin prescriptions. Foster said in his deposition
that he wanted to know whether the druggist made such calls whenever he saw
prescriptions for doses of a certain size.

He said he dropped in on pharmacists five to 10 times in relation to another
doctor, hoping to "build a teamwork approach" so the pharmacists would call
the doctor instead of regulators with any concerns.

Druggists sometimes reacted negatively to the large doses of OxyContin
called for in some prescriptions, he said, because they didn't understand
that the narcotic inside is released slowly over time, unlike other pain
pills.

Purdue's Hogen defended the visits as opportunities to offer pharmacists
needed education about OxyContin.

He said that some patients were "being stigmatized like junkies" when they
presented OxyContin prescriptions.

"Your friendly neighborhood pharmacist looks over his bifocals and says,
'Ah-ha. I see you are on OxyContin. What's going on here? Are you selling it
out of the station wagon to kids at school?'" Hogen said.

'Abused by bad people'

To Haj-Hamed, OxyContin is a good medicine that has been "abused by bad
people." The 37-year-old practitioner said he first prescribed it in 1999,
two years after he was licensed in Kentucky.

Purdue's "message" then, he said, was that OxyContin could restore an active
lifestyle to a pain patient with almost no side effects and that anyone
taking more than two competitors' pills a day was a candidate.

He began prescribing OxyContin with "great success." But by early 2001, "the
media made it like a doctor who writes the prescription and the patient who
takes OxyContin are like drug pusher and drug addict," he said. He scaled
back by 20 percent.

Some other doctors, hearing of lawsuits, patient arrests, suspicious
pharmacists and colleagues' warnings, referred pain patients to someone
else, he said.

Foster calmed the waters, Haj-Hamed said, advising him to closely follow
published guidelines on prescribing narcotics, and arranging meetings with
other doctors who believed in the drug.

In his deposition, Foster said his talks with Haj-Hamed were aimed at
"reassuring him that it is important to fight that battle and be willing to
help people" with untreated pain.
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