Opioid giant Mallinckrodt, selling more than Purdue Pharma in the US, was forced by the courts to publish more than 1.3 million internal documents.

In The BMJ, researchers Sergio Sismondo and Maud Bernisson sift through nearly 900 contracts which together reveal a carefully coordinated effort to shape medical attitudes toward pain medicine.

Pharmaceutical companies have a long history of managing physician and public opinion, explain the authors. For example, by recruiting physicians to serve as influencers, planting articles in scientific journals, coordinating conference presentations, and developing continuing medical education (CME) courses.

Amid surging concerns over an addiction crisis, Mallinckrodt faced growing hesitancy among frontline prescribers. But the contracts show how the painkiller manufacturer employed each of these tactics as it sought to reframe concerns about addiction as a phobia and muddle the very concept of dependence as "pseudoaddiction." It even went so far as casting opioids as preventive medicine for chronic pain.

"It's like they used every trick in the book," says Robert Steinbrook, director of the Health Research Group of the advocacy organization Public Citizen.

To many busy physicians, these messages would have appeared as trustworthy scholarship and evidence-based guidance, Sismondo and Bernisson explain.

The documents include a Mallinckrodt regulatory expert describing how its CME program "underscores Mallinckrodt's credibility with the FDA as a company that cares about … safe opioid prescribing," while a sales manager's exhortation in a 2013 email to the reps under him states, "You have only one responsibility, SELL BABY SELL!"

Adriane Fugh-Berman, professor of pharmacology and physiology at Georgetown University, who has been researching the marketing tactics of the pharmaceutical industry for 30 years, adds that "creating the term pseudoaddiction and distorting the terms tolerance and dependence were strategies that distracted physicians from noticing their patients were addicted."

In spite of settling with the US government for lax handling of its opioid supply and later being ordered to pay $1.7 billion over accusations of misleading and deceptive marketing practices to boost opioid sales, Mallinckrodt continues to sell opioids today, with sales of some $262 million in 2023, up 25% from the year before.