Targeted marketing of Duragesic™ (transdermal fentanyl patch)
In the early 1990s, Alza Corporation developed the first transdermal opioid delivery system, the Duragesic™ patch, which was marketed by Janssen Pharmaceuticals. Duragesic quickly became one of the most profitable opioids on the market, with sales in 2004 estimated at $2.4 billion(36). Internal business planning documents from 2000–2004 revealed that Janssen targeted Duragesic to older adults and the elderly population. Duragesic business planning was completed using SWOT Analysis (Strength, Weaknesses, Opportunities, Threats); eldercare, long-term care facilities, and the growing senior population were repeatedly identified as a business strength and opportunity(26, 37–39). Analysts for Janssen also frequently listed “limited clinical data(26, 37, 40)” as weakness of the Duragesic brand and “limited evidence-based scientific data(39)” as a growth inhibitor. A 2001 business analysis went a step further, and labeled a “move toward evidence-based prescribing(37)” as a threat to Janssen’s Pain Franchise ambitions, including Duragesic. In 2003, Janssen business planning clearly spotlighted elderly patients: “The market potential [of long-term care facilities] has been universally recognized”, “Janssen/J&J remains well positioned within this highly desirable segment”, and “ULTRACET [sic] and DURAGESIC [sic] also offer growth opportunities in the LTC [long term care] Market.”(38)
Given concerns about limited clinical data, the Janssen sales team marketing Duragesic significantly altered its core strategy in 2003 to focus on “physical and social functioning(41)”. Advertisements in 2003 and 2004 used the taglines “Life, Uninterrupted” and “Work, Uninterrupted” to advance the message of “chronic pain relief that supports functionality(39)”. This message was capitalized in business strategies that targeted patients in long term care facilities, including elderly patients in both nursing homes and assisted living(38), which were identified as a “strategic customer segment[s](26)”. Within long term care facilities, Janssen’s business goal was described as a “continued emphasis on the under treatment of pain in elderly patients to effectively position DURAGESIC…(26)” with an accompanying plan of “deliver[ing] targeted promotional tools through [the] ElderCare sales force which will leverage the functionality message to differentiate DURAGESIC.”(26) This plan to target elderly patients with an emotional appeal of functionality was given a budget of $500,000 for 2003(26).
Funding patient advocacy initiatives
Appeals to functionality and quality of life were not limited to Janssen’s marketing of Duragesic. In 2009, the American Academy of Pain Medicine and the American Geriatrics Society used funding from PriCara to release Finding Relief: Pain Management for Older Adults, a brochure and accompanying video that proposed to raise awareness of acute and chronic pain among older patients(28, 42). Like Duragesic’s functionality claims, the video script and brochure were deeply interwoven around an emotional message, specifically the fear of leading a handicapped and unfulfilling life without pain medications. In the Finding Relief video, Dr. Rollin Gallagher, Director of Pain Management at Philadelphia Veterans Affairs Medical Center, warned “after a long time of having chronic pain, you may not be able to socialize with your friends, do your hobbies, make love to your spouse, play with your kids or grandkids(28)”. Finding Relief implied on multiple occasions that opioids allowed older patients to continue enjoying life. The video included “scenes of various patients doing active things” with a voiceover stating “Used properly, opioid medications may make it possible for people with chronic pain to return to a high quality, more functional life.”(28) Similarly, the brochure stated that opioid medications allow older adults to “return to some activities – get back to work, walk or run, play sports, and participate in other activities.”(42)
The outreach program also minimized the risk of addiction. In the video, Dr. Bruce Ferrell, Professor of Medicine at UCLA, stated that, “oftentimes, [the patient’s] fears [about drug addiction and drug dependence] of these medications [opioids] are probably over-emphasized, or out of proportion to the real risk involved in their use.”(28) The brochure included a list of various “Opioid Myths” that claimed, without evidence, that “Many studies show that opioids are rarely addictive when used properly for the management of chronic pain [emphasis in original]” and “When used correctly for appropriate conditions, opioids may make it easier for people to live normally [emphasis in original].”(42)
Emotional appeals: functionality & quality of life
Intimidating older adults with a warning of poor quality of life without pain treatment is a theme seen in multiple documents. In June 2006, the Pain Care Forum provided lawmakers with strategically chosen new articles that perpetuated the message of undertreated pain in elderly patients:
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A 2006 article from the Desert Morning News titled “Painful choices: Physicians challenged by quest to end suffering” claimed that “Nursing home patients have historically been some of the most undertreated for pain. The complains of fragile elderly are sometimes dismissed as ‘normal aging’.”(22)
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A separate 2006 article from The Washington Post titled “Pitching Relief” reported the story of Wendy Shugol, a 54-year old wheelchair bound woman due to cerebral palsy. Shugol noted that she could not get out of bed “if not for the massive opioids she takes daily” and highlighted “the active life she can now live because of the opioids”(22). The physician who prescribed Shugol the opioids, Dr. Howard Heit, lauded the use of “high dose” opioids and claimed to have “seen the drug (in conjunction with proper monitoring) provide remarkable relief.”(22) The article failed to mention that Dr. Heit had previously provided consulting services for Actiq™ in 2004, a fentanyl product from Cephalon(43). Of note, Heit also asserted that he “doesn’t use prescription opioids for his own pain now.”(22)
In June 2007, Ortho-McNeil presented a summary of their “Non-Branded Promotion” which included the marketing pitch that “the under treatment of pain and its consequences can affect some patient groups more than others (i.e. elderly)” and the distribution of “patient vignette[s]” and “lively stories” that “highlight[ed] elderly patients.”(44) In February 2012, Kimberly Deem-Shleman of Johnson and Johnson worked with the American Pain Foundation to publish Pain Resource Guide: Getting the Help You Need, a brochure aimed at educating patients about pain and pain treatment; Johnson and Johnson’s involvement is not declared in the brochure itself(45). The brochure warned that untreated pain can lead to “limit[ed] ability to work, sleep, exercise, or perform everyday tasks (for example, dressing, going to the grocery story) and “reduce[d] mobility” and included pictures of a smiling group of older adults enjoying a workout(45). The brochure attempted to minimize the risk of addiction from opioids with a subsection labeled “Setting the Record Straight on Addiction”(45):
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“Many people living with pain – and even some healthcare providers – falsely believe opioids are universally addictive.”
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“Unless you have a past or current history of substance abuse, the chance of addiction is low when these medications are prescribed properly and taken as directed.”
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“Still, those who suffer with chronic pain and a substance abuse problem (addictive disease) deserve the same quality of pain treatment as others.”
In 2012, Janssen continued its pursuit of older adults as targets for opioid sales with a message that preyed on the fear and worry of the elderly community, specifically that of losing the ability to participate in activities that promote fulfilment in life. Public relations research for Janssen’s Pain Franchise in February 2012 focused on elderly patients recovering from surgery with the pitch “bouncing back from pain (29)”. These advertisements were then concentrated to venues that cater to older adults: “weekend morning shows, retirement markets…retirement community pub[lications], senior pub[lications]…caregiver columnists…”(29) Furthermore, in June 2012, the Advocacy/Policy team for Jansen’s Imagine the Possibilities Pain Coalition, with the explicit goal of “chang[ing] the conversation about pain”(30), identified “young elderly” as a target and planned to design an appeal of “quality of life – FULLNESS OF LIFE (sic).”(33)