I n the United States, Purdue Pharma, the drugmaker accused of fueling the opioid crisis through its aggressive marketing of highly addictive pain pills, is bankrupt and facing thousands of lawsuits.

Globally, its counterparts are selling opioids — and still profiting.

Among the beneficiaries: some members of the Sackler family, who own Purdue and also sit atop a group of international companies known as Mundipharma, records show. The family faces a wave of litigation over Purdue’s alleged role in an opioid crisis that has claimed hundreds of thousands of lives and ruined countless more across the United States.

From 2020 to 2022, nine Mundipharma companies in Europe and Australia made profits of $531 million on sales and distribution of pharmaceutical and other products, according to a first-of-its-kind analysis conducted as part of an investigation by journalists in eight countries. Total profits are probably higher because the figure does not include amounts, if any, from Mundipharma companies in jurisdictions that do not require disclosure of financial data.

The analysis provides a glimpse into Mundipharma’s value to possible buyers as the Sacklers approach a Sept. 27 bankruptcy court deadline that could end mediation meant to determine how much the family could have to pay to settle lawsuits relating to the opioid crisis. 

The Sacklers have previously pledged to sell their international companies to compensate U.S. cities, states, tribes, victims and others ravaged by the epidemic. Purdue, based in Stamford, Connecticut, still sells opioids such as oxycodone, though the company has been saddled with years of investigations, litigation and a massive bankruptcy reorganization.

Some of the same tactics used to persuade a generation of American doctors that potent painkillers could be safely prescribed have been used abroad, the investigation found.

In Germany, Mundipharma sponsored a patients group that, on its website, encourages opioid use for chronic pain while minimizing addiction risk. In Italy, prosecutors accused two Mundipharma managers of illegally paying kickbacks to doctors to promote opioids, allegations the company disputes. In China, an internal company investigation raised concerns that scientific advisory boards were used as vehicles to promote products.

And in Brazil, the international reporting collaboration found the company paid prominent doctors to hold evening classes on treating pain. In a statement, Mundipharma said its products are “not likely to play a major part in any abuse of opioid prescription medicines” in that country, an assertion challenged by some addiction experts.

Mundipharma also said “strong” opioids now make up a smaller share of the companies’ total sales as they have diversified into other treatments. It stressed that the companies strive to adhere to local laws and regulations and work with local authorities to monitor for drug diversion or abuse.

“We recognise that there are risks associated with the use of prescription opioid medications, so all employees, regardless of role, undertake mandatory opioid awareness training,” the company said.

Pain and addiction specialists warn patients worldwide remain at risk.

“When opioids are being prescribed aggressively, people are getting addicted, lives are being ruined, communities are being devastated,” said Andrew Kolodny, medical director of the Opioid Policy Research Collaborative at Brandeis University near Boston. 

While they haven’t experienced the heights reached in the United States, opioid prescriptions and overdose deaths across Europe and other parts of the world have increased during the past decade “because the drug companies are using the same playbook as in the U.S.,” said Kolodny, an outspoken critic of opioid overprescribing who has served as a paid expert for plaintiffs in opioid litigation and has testified in court and Congress about drugmaker practices.

To tell this story, journalists from The Examination, The Washington Post, Finance Uncovered, Paper Trail Media, Der Spiegel, ZDF and other news outlets reviewed thousands of pages of public and sealed court documents, academic papers, company filings and websites of company-sponsored groups and spoke with doctors, patients, researchers and more than a dozen former Mundipharma employees.

The Sacklers said family members play no operational role in Mundipharma. In a  statement, the families said they are focused in the United States on reaching a legal resolution that “provides substantial resources for people and communities struggling with a complex health crisis in America and not on regurgitated narratives that perpetuate false and misleading claims about their integrity.”

Purdue declared bankruptcy in 2019, prompting years of litigation. The U.S. Supreme Court overturned a bankruptcy plan in June, resulting in mediation as attorneys work to salvage a deal. The plan had called for the Sacklers to pay up to $6 billion over 18 years to settle lawsuits while relinquishing ownership of the company. 

Critics say the deal that was initially proposed went easy on the family. The U.S. Justice Department and Purdue creditors alleged the Sacklers withdrew nearly $11 billion from the company in the years before it declared bankruptcy as part of a “milking program” designed to protect the family’s wealth, according to court filings – a charge the Sacklers have consistently denied. The Sacklers, who themselves did not file for bankruptcy, have said nearly half of the money went to pay taxes.

Lawsuits against the Sacklers, some of whom sat on the Purdue board, allege company sales reps ramped up marketing to doctors even after the company pleaded guilty in 2007 to misleading regulators about the dangers of its blockbuster drug OxyContin. The Sacklers have long denied wrongdoing. In agreeing to pay $225 million in civil damages to the Justice Department in 2020, the Sacklers who served on Purdue’s board said “the board relied on repeated and consistent assurances from Purdue's management team” that the company was complying with the law.

The Sacklers, whose surname still adorns some museums and university buildings, have become the subject of books, documentaries and fictionalized TV shows. The family has branches in Europe and the United States.

Brothers Raymond and Mortimer Sackler bought Purdue in 1952 and incorporated the first Mundipharma company in Switzerland five years later. The Sacklers acquired Napp Pharmaceuticals, a little-known British firm, in 1966. 

By 2021, the Sacklers’ international companies had become a sprawling network of more than 170 entities registered in more than 40 countries, according to court documents.

The complicated constellation of Mundipharma companies and Sackler-related overseas trusts figured into litigation involving Purdue as attorneys sought to gauge the family’s wealth. The Sacklers have long said they have been transparent about their finances as part of legal proceedings.

Mundipharma said it and Purdue are independent companies “with only limited business interactions.”

To build a picture of Sackler family international businesses, the reporting collaborative worked from a list of “independent associated” companies released as part of the Purdue bankruptcy and obtained company filings from corporate registries around the world. 

Mundipharma companies logged an estimated $2.5 billion in sales in Australia, China and Europe’s top-five economies from 2020 to 2022, the analysis found. 

The Sacklers have not waited for the U.S. settlement negotiations to end before selling off parts of their international businesses. 

Last year, they sold a brand portfolio led by antiseptic spray Betadine to iNova Pharmaceuticals in a deal valued at $540 million, with proceeds earmarked to resolve opioid legal claims in the United States, according to Emma Keogh, senior corporate communications manager at iNova. They also sold their controlling share in Israeli pharmaceutical company Rafa Laboratories for about $200 million, according to financial news website Globes. It is not known if these funds are also held in escrow or available to the family. 

In addition, corporate filings show five Mundipharma companies have paid $287 million in dividends since 2020, although it is not clear where those payments ultimately went. The Sacklers and Mundipharma separately did not answer specific questions about finances. 

A global wave of overdoses

In Europe and elsewhere, pharmaceutical marketing regulations and drug approval systems may guard against reaching the scale of America’s opioid crisis, experts say. And there’s wider access to buprenorphine and methadone, drugs used to treat opioid use disorder.

Pain afflicts millions globally, according to the World Health Organization, which says morphine and other opioids are essential for treating pain associated with surgeries, cancer and other emergency care but are difficult to obtain in many low-income countries. Still, pharmaceutical industry practices are contributing to more overdoses and addiction, especially when doctors too aggressively prescribe opioids after surgeries or to patients with conditions such as long-term back pain or arthritis, critics say.

“There's very little evidence that they're actually useful” for chronic pain, said Kyla Thomas, a doctor and professor of public health medicine at the University of Bristol.

Thomas led a team of researchers that analyzed 148 international studies involving more than 4.3 million patients and concluded in a study published in August, that about a third of the patients prescribed opioids for chronic pain not related to cancer exhibited problematic opioid use. 

Data on global prescription opioid use and addiction is imprecise. Between 2015 and 2019, prescription opioid consumption in 66 countries rose by an average of nearly 4% each year, according to research published in Lancet Public Health, with notable declines in the United States and some European countries.

Across the European Union, overdose deaths from all drugs spiked nearly 20% between 2010 and 2022 and continue to rise, according to the E.U. Drugs Agency, which collects data on drug use and addiction. The figure excludes Germany — the most populous nation in the E.U. — because it changed the way it counts the deaths. Opioids, whether prescribed or illicit, were found in nearly three-quarters of all overdose deaths. 

In Europe, heroin remains a persistent problem. Europe has not been ravaged by fentanyl as in the United States, where illicitly manufactured synthetic opioids have become by far the nation’s deadliest drug.

In Norway, prescription opioids overtook heroin as the most frequent cause of overdose deaths in 2016, according to government statistics. In a country of just under 6 million, about 60,000 people who got opioid prescriptions in 2019 met the criteria for “persistent” use, a study found.

Two years ago, Norway’s national health agency launched a review of Mundipharma advertising to doctors after questions were raised by a public broadcast investigation. It found that between 2001 and 2009, Mundipharma in advertising downplayed addiction risks. The advertising could have contributed to increased oxycodone prescriptions, said Sigurd Hortemo, senior medical consultant at the agency and author of the report. 

Mundipharma said it has not promoted opioids in Norway since 2013. And efforts to expand the overall European market “have been minimal … there has been no promotion for many years,” the company said in a statement.

In Sweden, deaths linked to oxycodone – which is produced by several drug manufacturers – increased tenfold between 2006 and 2022, according to a study by Gunnar Ågren, former director general of the Swedish National Institute of Public Health. Most people who overdosed on prescription opioids had been prescribed the drugs for pain, Ågren said. Oxycodone is now the most common opioid in fatal intoxications, he said.

“I don't think Sweden's physicians are very aware of the risk with opioid prescription,” Ågren said. Many read about the opioid epidemic and say: “Okay, that's the United States … that's not our problem,” he said.

The battle against addiction

Though Purdue Pharma still sells opioids in the United States, it stopped promoting them to doctors in 2018 as part of the ongoing litigation. In other regions, it has been a different story.

In South America, Mundipharma provided $39,000 in funding to a medical professionals group called the Brazilian Society for the Study of Pain between 2019 and 2023, the company acknowledged. Mundipharma also paid Carlos Marcelo de Barros, now president of the society, for an online lecture about treating pain, according to the doctor and the company.

De Barros also helped write legislation proposed this year in the Brazilian Congress by politician Bia Kicis. The bill proposes standardizing treatment in the public health system and ensuring that medical and nursing colleges have specialized training on treating pain.The bill also proposed designating a national day of awareness about chronic pain. 

De Barros said via email that the company had no input in the bill intended to address “terrible” education about chronic pain in Brazil. “Many patients with difficult-to-control pain cannot access medication,” de Barros said. The challenge for Brazil is to expand access while preventing a crisis akin to what unfolded in the United States, he added. 

Kicis said she was unaware of Mundipharma's funding to de Barros or the pain society, was not approached by the company and emphasized that the legislation will help suffering Brazilians.

Mundipharma introduced a medication called Targin in 2021, which combines oxycodone with naloxone to prevent opioid-related constipation. A Mundipharma-branded video posted on a Brazilian production company’s YouTube page touts the benefits of the medication while saying the drug company aims to make 2023 the “year of Targin.”

When asked about its promotion of Targin, Mundipharma acknowledged the risk of opioids but said any attempt to abuse the medication is countered by naloxone, which also reverses opioid overdoses when inhaled or injected. It also pointed out it sells OxyContin in an abuse deterrent formulation that makes it difficult for users to crush pills for a more potent effect. “Accordingly, Mundipharma products are not likely to play a major part in any abuse of opioid prescription medicines in Brazil,” the statement said. 

Multiple medical experts pushed back on the company’s claims about risk, saying although Mundipharma’s abuse deterrent formulations may discourage patients from snorting or injecting these pills for a stronger high, many patients become addicted when using the medications as directed. Patients can still overdose if enough pills are swallowed, they said.

In the United States, Purdue introduced an abuse deterrent formulation of OxyContin in 2010 and promoted it as a safer alternative. In 2020, experts from the U.S. Food and Drug Administration concluded that no robust evidence existed that the abuse deterrent formulation caused “a meaningful reduction in overall OxyContin abuse.”

“It’s clear to me that Mundipharma is using the same tricks to promote Targin that Purdue used to promote OxyContin in North America in the 1990s and 2000s,” said David Juurlink, head of the division of clinical pharmacology and toxicology at Sunnybrook Health Sciences Center in Toronto. “Doctors here fell for the messaging. I hope Brazilian doctors learn from our mistakes.”

Data on opioid-related deaths in Brazil is murky. Between 2012 and 2020, overdose deaths from all drugs increased by an average four percentage points a year, according to a study in the Brazilian Journal of Psychiatry. But most death records did not state the drug involved.

In April 2023, Instituto Perdizes do Hospital das Clínicas de São Paulo established an opioid outpatient clinic “due to a huge shortage in the treatment of people who use opioids in Brazil,” said Mariana Campello de Oliveira, a program psychiatrist and addiction specialist.

She said patients who have been prescribed opioids for pain represent the largest group referred to the clinic, which has treated about 100 patients.

De Oliveira said she is alarmed at the lack of opioid prescription data. “We are in the dark, we are blind, how [addiction] has grown,” she said.

Thousands of miles away in China, Mundipharma conducted an internal investigation after a 2019 Associated Press report found cases of company sales representatives telling doctors that time-release OxyContin was less addictive than other opioids, pushing larger doses of the drugs and, at times, donning white coats to misrepresent themselves as medical professionals to patients.

People with direct knowledge of the company’s operations in China told the reporting collaborative an internal investigation raised concerns about Mundipharma’s use of scientific advisory boards, which are normally designed for companies to receive input from scientific and medical professionals. The people, who spoke on the condition of anonymity out of fear of retribution, said the internal review indicated that the board meetings instead were used as vehicles to promote products and pay doctors.

The internal investigation found Mundipharma lacked clear rationale when selecting professionals to sit on some advisory boards and that more than 1,000 health-care workers were paid as advisers in 2019, according to documents seen by the reporting collaborative.

Mundipharma said an independent law firm investigated after the Associated Press story and that the company implemented improvements to its compliance program in China. It declined to detail the investigation’s findings. “There is no issue with scientific advisory boards in China or elsewhere,” it said in a statement to the reporting collaborative. 

In 2019, regulators in Australia fined Mundipharma about $200,000 for advertising relating to Targin. The country’s health agency called the ads “misleading, imbalanced and otherwise inaccurate.” Mundipharma said the agency misinterpreted one line about opioids as part of pain management in promotional materials.

Unintentional opioid overdoses in Australia more than doubled from 2002 to 2022, according to a report by the Penington Institute, a public health research and policy organization. As the government has tightened access to prescription opioids during the past decade, overdose deaths tied to oxycodone, morphine and codeine have decreased substantially while heroin deaths increased.

Julianne Hebbe, 45, a patient from Australia, said she and her boyfriend at the time, already struggling with alcohol addiction, became dependent on oxycodone in about 2009 after it was prescribed to him following surgery. Two years later, when they couldn't get the drug anymore, she said, they switched to heroin. “It totally destroyed our lives.”

She entered rehab soon after. Today, the mother of four is off heroin, regularly sees an addiction specialist and must take buprenorphine, an opioid that keeps her withdrawals and cravings at bay. She has tapered herself down over a decade but still wants off the medication because it has caused trouble sleeping. “I just want totally out of it,” she said.

Establishing a foothold in Europe

Mundipharma companies contributed more than $15 million to European health-care organizations, professionals and patient groups for purposes such as events, sponsorships and consulting between 2019 and 2021, according to data based on voluntary industry disclosure assembled by transparency project Euros for Docs. The figure includes five European countries and is dominated by the United Kingdom and France; it excludes Germany and other countries where Mundipharma has not disclosed payments. 

In Italy, prosecutors accused two Mundipharma managers in 2019 of illegally paying an anesthesiologist at a public university hospital to promote opioids. The employees accepted plea deals and the company accepted a fine of about $44,000 without admitting liability. The anesthesiologist, who also was charged, was acquitted last year after concerns were raised about law enforcement use of wiretapping, according to local news reports.

The company described the plea deals, which resulted in no admissions of liability, as a “business decision” to avoid years of litigation. “Had Mundipharma and its managers chosen to fight the case, it is likely they would also have been acquitted of all charges,” a company statement said.

Internal emails obtained by the reporting collaborative show that some Sackler family members had close contact with executives at Mundipharma companies in various countries, including Germany. In a November 2013 email, Mortimer D.A. Sackler, who according to internal documents was listed as a director of four Mundipharma companies in Europe at the time, questioned one executive about projected sales of pain medication.

“I am surprised the sales plan for next year isn’t higher. Why the conservatism?” Mortimer D.A. Sackler wrote. “The five year plan for Germany is totally unacceptable. What is being done to improve it and put it back on a growth track?...I am surprised that we don’t think we can grow our overall analgesic business over the next five years.”

Neither Mundipharma nor a Sackler family spokesperson addressed questions from the reporting collaborative about the email. 

By 2018, sales from Mundipharma in Germany topped $300 million annually, according to financial disclosures. The company’s overall sales in Germany have dropped amid downsizing but profits have ticked up since 2020, financial disclosures show.

Similar to Purdue and other opioid companies in the United States, Mundipharma in Germany funded patient and medical organizations that advocated use of opioids.

The German Society for Pain Medicine receives funding from Mundipharma and trains health-care workers in managing patients with pain, according to the society’s website. It was co-founded in the early 1980s by Harry Kletzko, a now-retired health-care consultant who worked as an executive for Mundipharma between 1988 and 2001, according to his LinkedIn profile and former employees. In the years since, he has served as a manager for the society, according to a statement by the group. Kletzko declined to answer questions from the reporting collaborative. 

“Mundipharma was an important producer of innovative opioid therapy products in Germany,” the society’s current president, Johannes Horlemann, said in a statement, crediting the company’s extended release pills as one of the main reasons there has not been an opioid crisis in the country.

Kletzko was also once vice president of another Mundipharma-funded organization, a patient support and advocacy group called the German Pain League. 

Mundipharma said it paid about $8,500 per year in standard annual membership fees combined to the two organizations between 2021 and 2024 and that it does not promote products through the groups. 

The Pain League website says opioids are “usually well tolerated even in long-term therapy” and touts the extended-release type of the drugs.

Parts of the website are “undoubtedly aimed at convincing patients and doctors that opioids should be prescribed for ALL … types of pain,” which “clearly contradicts current scientific evidence and guidelines,” Christoph Stein, professor emeritus of anesthesiology at Charité University Hospital Berlin, said in an email. 

Kolodny, of Brandeis University, said extended-release pills are riskier because they have to be taken in higher doses and around-the-clock, not just during episodes of pain. He noted that the opioid section of the Pain League’s website does not mention addiction and overdose and instead lists nausea, vomiting and constipation as side effects. 

“They should get this off their website immediately,” Kolodny said.

Pain League president Michael Überall, a German pain specialist who has acknowledged in a research paper financial ties to Mundipharma and other drug companies, referred in a statement to a German guideline recommending extended release opioids over short acting ones. He said that in practice, opioids help patients more than clinical trials suggest and addiction is rare.

‘Much dumber’ than the Americans

Vera Brunner, 58, from Germany didn’t know about the addiction risk of oxycodone when her doctor prescribed it for hip and back pain five years ago. “Later, I did some research on the internet and I heard all about America,” she said.

Every time Brunner tried getting off the pills — which she said included Mundipharma brands — she endured the nausea of withdrawal. She has taken oxycodone for more than four years while grappling with depression and suicidal thoughts. “I could no longer exist without oxycodone,” Brunner said.

She attended a rehab clinic at the end of last year, where her oxycodone has been tapered down — although the pain returned, underscoring the challenges pain patients face when trying to end long-term use. 

"We are entering into the same situation in Europe as in the United States 15 years ago,” said Andrea Burden, assistant professor of pharmacoepidemiology at the ETH Zurich university.“ We can’t assume we are smarter than Americans here in Europe. If we don't pay attention to the signs and act, we will prove ourselves to be dumber. Much dumber.” 

Contributing reporting by: Fernanda Aguirre of The Examination, Bruna Lima and Guilherme Amado of Metrópoles, Simon Bowers and Malia Politzer of Finance Uncovered, Maria Christoph and Dajana Kollig of Paper Trail Media, Max Hübner of ZDF, and Edoardo Anziano and Francesco Paolo Savatteri of IrpiMedia

The investigation was supported by a grant from the Investigative Journalism for Europe (IJ4EU) fund.

The article has been updated to reflect that Andrew Kolodny has served as a paid expert for plaintiffs in opioid litigation.