The Wall Street Journal - 20.09.2019

A8| Friday, September 20, 2019 THE WALL STREET JOURNAL.**

import-company employer to

conference rooms for a 20-min-

ute siesta. He endures suspi-

cious glances from Japanese

colleagues, he says. “You can

feel some of the people on the

Japanese side are judging us.”

The average person in Japan

sleeps 6 hours and 15 minutes

at night, an hour less than in

the U.S. and Switzerland, ac-

cording to the Organization for

Economic Cooperation and De-

velopment, which puts Japan at

the bottom of its list of devel-

oped countries. In France, it’s

7½ hours.

Japanese colleagues “leave

later, work harder and don’t nap,”

Mr. Lapouille says. “Once you re-

alize you can’t work as hard as

them, it makes it easy to nap.”

Takanori Kobayashi, CEO of

Tokyo startup NeuroSpace Co.,

which develops programs to

improve sleep quality for cor-

porate employees, has been try-

ing to bring the power nap to

Japanese corporations. He says

a nap—the real kind, lying back

20 to 30 minutes in the dark—

improves focus and productiv-

ity. Companies have been open,

FROM PAGE ONE

Purdue Led

In Higher

Dose Pills

One Store Was Big

Purchaser of Pills

A grocery-store pharmacy in

Knoxville, Tenn., bought nearly

one million high-dose OxyContin

pills in 2008, third-most in the

nation, according to a Wall

Street Journal analysis of data

from the Drug Enforcement Ad-

ministration.

In 2008, local residents be-

gan complaining that the store’s

parking lot had become a mag-

net for drugs and crime since

the pharmacy began filling pre-

scriptions for a nearby pain

clinic, according to a local news-

paper article.

A Purdue Pharma LP sales

representative informed the

company of the article about

the complaints, according to a

“Report of Concern,” a company

document that employees used

to report inappropriate use of

Purdue’s drugs,said Steve Seid,

a former Purdue executive, in a

deposition.

The article contained “state-

ments about OxyContin, Food

City Pharmacy” and a nearby

pain clinic co-operated by Dr.

Frank McNiel, the report said,

according to a transcript of Mr.

Seid’s deposition. In an email to

Mr. Seid, a Purdue account

manager said he would visit the

pharmacy to gather more infor-

mation.

Three years later, Purdue in-

formed sales reps to stop call-

ing on Dr. McNiel and referred

him to the DEA, according to

documents referenced in the de-

position.

In 2016, the Food City phar-

macy agreed to a consent order

with the Tennessee Board of

Pharmacy citing the store for

dispensing opioids and other

controlled substances in a man-

ner inconsistent with state law

and regulations, including by dis-

pensing drugs to patients who

had driven long distances to the

pharmacy, and accepting post-

dated prescriptions, and failing

to check a state prescription

monitoring database before dis-

pensing controlled substances.

In a statement, Purdue said

it “has a longstanding commit-

ment to preventing the diver-

sion and abuse of its products

in partnership with industry,

government and law enforce-

ment agencies. We take our

compliance obligations seriously

and will continue to defend our-

selves vigorously against any

misleading allegations implying

otherwise.”

A spokeswoman for Food

City’s parent, K-VA-T Food

Stores, said in an email that the

company has refined its phar-

macy practices in consultation

with drug-enforcement experts,

including by not filling out-of-

state prescriptions. K-VA-T

hasn’t been accused of wrong-

doing by law enforcement, the

spokeswoman said.

Dr. McNiel in March 2018

surrendered his medical license

to resolve a disciplinary investi-

gation by the Tennessee Board

of Medical Examiners.

“I didn’t prescribe these

drugs for entertainment,” Dr.

McNiel told the Knoxville News

Sentinel last year. “Chronic pain

patients have to have some

kind of quality of life.”

—Joseph Walker

phlets on efficient napping. He
advertised the initiative among
its 850-some employees and un-
veiled an online nap-scheduling
calendar.
Business has been sleepy.
Some people “probably
thought, ‘Why waste time nap-
ping?’ ” says Mr. Negami. “Even
I felt the pressure to justify go-
ing for a nap.” He naps in the
designated rooms, hoping to
lead by example.
Mr. Negami’s superior, Bun-
roku Naganuma, says he has used
the rooms but prefers sleeping at
his desk: “Seems like most peo-
ple in Japan nap that way.”
At the offices of Bitflyer
Blockchain Inc., Japan’s largest
digital-currency exchange, CEO
Yuzo Kano says he installed,
then uninstalled, a room with a
bunk bed. Of his 250 employ-
ees, he says, maybe only three
used it to take naps.
It isn’t that Japan has a taboo
against public sleeping, as a typ-
ical late-night train shows. What
stigmatizes the nap room, say
workers, is the premeditated na-
ture of the napping.
Nodding off at one’s desk is
admirable or at least pardon-
able, because it highlights one’s
hard work and grueling hours.
Making a nap-room reservation

ContinuedfromPageOne

looks like slacking off.

“Working long hours with-

out a break and everyone work-

ing together until the end of

the day, this is traditionally

how Japan has done things,”

says Reina Hyakuya, a manager

at Nextbeat Co., a Tokyo re-

cruitment-consulting firm.

She says that she uses nap-

ping chairs in Nextbeat’s lounge

floor but rarely ventures into

its nap rooms, which are dark,

equipped with aroma diffusers

and white-noise machines—and

require a reservation.

Brigitte Steger, a University

of Cambridge lecturer who has

studied Japanese sleeping hab-

its, distinguishes between a nap

and what Japanese call inemuri ,

or roughly “nodding off.” The

Japanese characters for the

word more literally translate as

“sleeping while present.”

“Inemuri is very different”

from a nap, says Dr. Steger. “It’s

not taking off your shoes and

withdrawing, it’s actually, ‘I am

actually at work.’ You are still

officially working even if you

drop off.”

Dr. Seiji Nishino, who runs

Stanford University’s Center for

Sleep Sciences and Medicine,

says Americans tend to view

the outcome of their work as

important, whereas Japanese

are more focused on the pro-

cess, including “how they are

seen working hard.”

Being seen in a designated

nap room would be a waking

nightmare.

Louis Lapouille moved to

Japan a year ago from France

and sometimes heads with

French co-workers at his Tokyo

but pushback has come from

employees: “There is this cul-

ture, you respect someone who

doesn’t sleep much.”

Bedding maker Nishikawa

Co. created a line of pillows for

snoozing at the desk, designed

to avoid facial sleep marks.

Some have a face hole to pre-

vent smudged makeup.

“If you take a nap at your

desk, your arms and hands may

directly touch your face, leaving

marks and causing your hands

and arms to fall asleep,” says

spokeswoman Kazue Kasuga,

adding that the office-snoozing

pillows are outselling the com-

pany’s home-snoozing lineup.

Nestlé SA unit Nestlé Japan

in March opened a “Nescafé

Sleeping Cafe” in Tokyo, where

customers drink coffee and doze

in a dark room to flowing-water

sounds. The caffeine takes half

an hour or so to kick in, and the

idea is to get a power nap and

wake up ready to go. Staff say

business is good and the most

frequent customers are workers

who pop in for a quick rest

away from the office.

Tokyo internet-services com-

pany GMO Internet Inc. decided

to foster nonjudgmental work-

napping by setting a company

nap period starting after lunch

and inviting all employees to do

it together. It created a commu-

nal nap space with 27 cots.

At its busiest, says spokes-

woman Sae Takahashi, about

80% of the cots are occupied.

“The ease of going to the nap-

ping room—the hurdle employ-

ees have to overcome to make it

there—is probably lower for a

communal nap space,” she says.

Japanese

Shun the

Nap Room

tion opioids never exceeded
4%.
Purdue and the Sackler
family that owns it are trying
to resolve some 2,600 lawsuits
from states, cities and coun-
ties that accuse the company
of helping spark the nation’s
opioid crisis through its ag-
gressive marketing. On Sun-
day, the company filed for
bankruptcy protection with a
partial deal aimed at resolving
most of the suits.
Purdue and family members
named in lawsuits have broadly
denied the allegations and have
said they are committed to
helping curb opioid addiction.
In recent years, the rapid in-
crease in overdose deaths has
been driven primarily by illegal
opioids like heroin and illicit
fentanyl. But from 1999 to
2014, prescription drugs like
oxycodone, hydrocodone and
others were the leading causes
of opioid overdose deaths in
the U.S., according to data
from the federal Centers for
Disease Control and Preven-
tion.
A 2013 study published in
the journal Pain found that
oxycodone was the preferred
opioid for 45% of 3,500 opi-
oid-dependent people entering
addiction treatment around
the U.S., compared with about
29% of those who preferred
hydrocodone.
Oxycodone was present in
33% of overdose deaths re-
lated to prescription opioids,
the most of any drug, and
nearly twice the share of hy-
drocodone-linked deaths, ac-
cording to a CDC analysis of
state medical-examiner data
from 2009.
The CDC defines high-dose
pills as the equivalent of more
than 33 milligrams of oxy-
codone. The risk of overdose
nearly doubles when a patient
takes more than 33 milligrams
of oxycodone a day, according
to the agency.
The average strength of
OxyContin pills purchased by
retail and mail-order pharma-
cies during the seven-year pe-
riod the Journal reviewed was
41 milligrams, about three
times the second-highest aver-
age dose—14 milligrams—
among the 10 largest oxy-
codone pill makers, as
measured by number of pills.
The highest-strength pill made
by Purdue was 80 milligrams,
and represented 25% of all
OxyContin pills it sold during
the period, according to the
Journal’s analysis. Purdue was
the fourth-largest oxycodone
maker from 2006 to 2012.
Higher-dose opioids also
can be more lucrative for drug
traffickers because the pills
command higher prices on the
black market, said DEA Deputy
Assistant Administrator Tom
Prevoznik in an interview. This

ContinuedfromPageOne

was true for OxyContin, espe-

cially before Purdue switched

to a formulation in 2010 de-

signed to make OxyContin

tougher to abuse. When Oxy-

Contin’s popularity was at its

height in the mid- to late

2000s, the pill had a street

value based on dosage—$1 per

milligram in many cities, ac-

cording to law-enforcement

officials.

Inside Purdue, company of-

ficials knew high-dose pills

posed a particular risk, and

large orders of high-dose Oxy-

Contin by pharmacies and

wholesalers were a red flag

that the pills might be di-

verted, according to court doc-

uments.

“At the risk of stating the

obvious, two observations

come to mind: 40-milligram

and 8[0]-milligram strengths

are the most diverted, misused

and abused,” wrote Aaron Gra-

ham, Purdue’s former vice

president and chief security of-

ficer, in a 2007 email read dur-

ing the deposition of another

former Purdue official, Steve

Seid. Mr. Seid was deposed last

year in a consolidated case of

hundreds of lawsuits against

Purdue and other companies.

Mr. Graham declined to

comment. Mr. Seid didn’t re-

spond to requests to comment.

High-dose pills were a part

of Purdue’s sales and market-

ing strategy, according to a

lawsuit filed last year by the

Massachusetts Attorney Gen-

eral’s Office against Purdue

and the Sacklers, and docu-

ments released in the case. In

promotional materials from

2008, Purdue emphasized that

OxyContin came in several

dosage strengths, allowing

doctors to increase patients’

dosages in increments of 25%

to 50% as “clinical need dic-

tates,” according to the Mas-

sachusetts complaint.

In 2008, Purdue launched

three new OxyContin

strengths, including a 60-milli-

gram dose, and expanded its

sales force by 100 sales repre-

sentatives, in addition to the

300 or so it already employed.

OxyContin sales more than

doubled to $2.3 billion in 2008

from a year earlier, its best

year ever up to that point, ac-

cording to data from health re-

search firm IQVIA Holdings Inc.

At the beginning of 2008,

the company directed sales

reps to increase visits to retail

pharmacies “as we introduce

the new strengths and as ge-

neric availability decreases,”

said Russell Gasdia, former

vice president of sales, in an

email released in the Massa-

chusetts litigation. A generic

competitor had exited the mar-

ket that year, further fueling

sales of OxyContin.

In 2009, Purdue staffers

noted in a report to the board

that “for the first time since

January 2008, OxyContin

80mg strength tablets ex-

ceeded the 40mg strength” in

sales, according to the com-

plaint.

Richard Sackler, Purdue’s

president from 1999 to 2003

and who served on the board

until 2018, took an interest in

quantifying OxyContin sales by

dosage strength, according to

documents in the Massachu-

setts complaint.

In a February 2008 email,

Dr. Sackler suggested to com-

pany executives, directors and

consultants that the company

“measure our performance by

[prescriptions] by strength,

giving higher measures to

higher strengths an[d] espe-

cially the new strengths,” ac-

cording to a copy of the email

included in the Massachusetts

case. Dr. Sackler, the son of a

Purdue co-founder, instructed

the executives to bring to him

“detailed [prescription] projec-

tions by strength and by

month.”

A representative for Dr.

Sackler didn’t respond to a re-

quest for comment. Mr. Gasdia

didn’t respond to requests for

comment, and his attorney de-

clined to comment.

In its statement, Purdue

said that during the period re-

viewed by the Journal, the

company had entered into a

corporate integrity agreement

with the U.S. government that

governed its sales and market-

ing practices for five years,

and required it to report to a

monitor with visibility into its

operations. Purdue said it suc-

cessfully completed the agree-

ment in 2012 “with no signifi-

cant adverse findings.”

The 2007 corporate integ-

rity agreement came as part of

a federal guilty plea by the

company to criminal charges

of misleading the public about

OxyContin’s addictiveness be-

tween 1995 and 2001. Purdue

agreed to pay $634.5 million

in penalties.

Meanwhile, law-enforce-

ment agencies were trying to

combat the rise of rogue phar-

macies diverting prescription

opioids onto the black market.

Some of these so-called pill

mills were among OxyContin’s

biggest customers, the Jour-

nal’s analysis of DEA data

found.

Of the 50 largest pharmacy

buyers of high-dose OxyContin

in 2008, when Purdue’s sales of

the drug doubled, at least six

were later sanctioned or crimi-

nally prosecuted for improp-

erly dispensing opioids or

other controlled substances.

Purdue sold most of its

OxyContin to wholesale dis-

tributors. But plaintiffs’ law-

yers representing the more

than 2,500 municipalities in

the litigation allege that Pur-

due and other drugmakers

knew or should have known

that drugs were being pur-

chased by pharmacies that

were potentially diverting

them onto the black market.

Purdue regularly purchased

data from its wholesalers

showing which pharmacies

were purchasing its drugs, giv-

ing the company “access to in-

formation regarding the pur-

chasing patterns of their

customers’ customers,” the

plaintiffs alleged in a July

court filing citing depositions

and company documents. In

court filings, Purdue has said it

“was ‘routinely’ in communica-

tion with the DEA and distribu-

tors about potentially suspect

pharmacy accounts.”

In a statement, Purdue said

it “has a longstanding commit-

ment to preventing the diver-

sion and abuse of its products

in partnership with industry,

government and law enforce-

ment agencies. We take our

compliance obligations seri-

ously and will continue to de-

fend ourselves vigorously

against any misleading allega-

tions implying otherwise.”

—Christopher Weaver

contributed to this article.

Strong Medicine

Purdue made about 10% of the pills containing oxycodone—the active

ingredient in OxyContin—purchased by U.S. pharmacies from 2006 to 2012,

but sold a greater percentage when weighted by dosage strength.

Oxycodone market share, by manufacturer, 2006-

Sales of 80 mg oxycodone pills

Share of oxycodone pill sales

volume, by strength, 2006-

40-80 mg

15-30 mg

10 mg or less

71%

13%

Note: Wall Street Journal analysis of recently released opioid sales data maintained by the U.S. government

Source: Drug Enforcement Administration ARCOS Database

By number of

milligrams sold

By number of

pills sold

Purdue was the

top manufacturer

of oxycodone pills

when weighted by

milligrams sold

26%

39%

Mallinckrodt

22% 22%

Actavis

Pharma

14%

17%

Par

Pharmaceutical

11%

12%

Other

27%

10%

Purdue

2%

Purdue Other manufacturers

150

0

25

50

75

100

125

million pills

2006 ’07 ’08 ’09 ’10 ’11 ’

Purdue Other manufacturers

At the Nescafé Sleeping Cafe in Tokyo, customers drink coffee, then doze to flowing-water sounds.

High-dose pills were

a part of its sales and

marketing strategy,

documents say.

NESTLE JAPAN