The pharmaceutical sales representatives from health care giant Abbott Laboratories had a problem. No matter what they tried, they couldn’t get the attention of an orthopedic surgeon to convince him to prescribe the potent painkiller OxyContin.

Week after week, they dropped by his office, sometimes bringing lunch for the doctor and his staff. Still, he had little time for them.

That is, until the staff let them in on a secret: “We were told by his nurses and office staff that the best way to capture his attention and develop our relationship was through junk food,” the sales reps wrote in an internal memo.

The next week, one of the Abbott representatives showed up with a sheet cake box filled with doughnuts and snack cakes arranged to spell out the word “OxyContin.” The gambit worked. The surgeon listened to the sales talk, and every week after that, the Abbott sales personnel visited the doctor to ask him to switch at least three patients to OxyContin from other painkillers.

The doughnut ploy, highlighted in a trove of internal documents obtained by STAT, shows the lengths to which Abbott went to hook in doctors and make OxyContin a billion-dollar blockbuster. The sales force bought takeout dinners for doctors and met them at bookstores to pay for their purchases. In memos, the sales team referred to the marketing of the drug as a “crusade,” and their boss called himself the “King of Pain.”

Purdue Pharma LP, the Connecticut company that developed OxyContin, has been vilified for planting the seeds of today’s opioid crisis, which kills an estimated 78 Americans a day. But the role of Abbott in pushing the drug has largely escaped notice. The documents reveal it was a crucial partner in the aggressive — and misleading — selling of OxyContin during its first decade on the market.

Abbott’s relationship with Purdue and its part in building the OxyContin brand are detailed in previously secret court filings unsealed by a Welch, W.Va., state court judge at the request of STAT. The records were part of a case brought by the state of West Virginia against Purdue and Abbott that alleged they inappropriately marketed the drug, causing users to become addicted to the opioid. The case was settled in 2004 when Purdue agreed to pay $10 million to the state. Neither company admitted any wrongdoing.

The documents include internal Abbott and Purdue memos, as well as sales documents and marketing materials. They show that Abbott sales reps were instructed to downplay the threat of addiction with OxyContin and make other claims to doctors that had no scientific basis. The sales reps from the two companies closely coordinated their efforts, met regularly to strategize, and shared marketing materials.

Abbott, a much larger company than Purdue, had a sales force entrenched in hospitals and surgical centers, and had existing relationships with anesthesiologists, emergency room doctors, surgeons, and pain management teams. Abbott devoted at least 300 sales reps to OxyContin sales — about the same number of people Purdue initially dedicated to the drug — as part of a co-promotional agreement with Purdue.

Winning Abbott’s help was so important to Purdue that it agreed to indemnify the larger company from any legal costs that might arise from the selling of the drug. It was a provision that ended up saving Abbott millions of dollars, and also kept the company out of the headlines as Purdue was forced to pay huge fines and settlements from the illegal marketing of OxyContin.

Abbott declined to comment about the marketing techniques outlined in the court documents, or disclose how much it was paid by Purdue to sell OxyContin. A spokeswoman’s only comment was that “Abbott was indemnified by Purdue in the lawsuit.” Abbott no longer sells pharmaceutical products in the United States, having split off that business into a new company in 2013.

Carrying the OxyContin banner into battle

Abbott marketed OxyContin from 1996 through 2002 — a critical period directly following the approval of the drug by the US Food and Drug Administration.

With Abbott’s help, sales of OxyContin went from a mere $49 million in its first full year on the market to $1.6 billion in 2002. Over the life of the partnership, Purdue paid Abbott nearly a half-billion dollars, according to court records.

At the deal’s end, OxyContin was one of the most abused prescription opioids in the country and was responsible for a corresponding wave of addiction and crime from West Virginia to Maine to Florida. West Virginia has the highest rate of fatal drug overdoses in the country — and the abuse of opioids has expanded from prescription painkillers to more potent drugs like heroin and fentanyl. Last month, the city of Huntington experienced 26 overdoses in just a few hours.

Abbott heavily incentivized its sales staff to push OxyContin, offering $20,000 cash prizes and luxury vacations to top performers. Their almost religious zeal to sell the drug is evident in the wide use of terminology from the Middle Ages Crusades: Sales reps were called “royal crusaders” and “knights” in internal documents, and they were supervised by the “Royal Court of OxyContin” — executives referred to in memos as the “Wizard of OxyContin,” “Supreme Sovereign of Pain Management,” and the “Empress of Analgesia.” The head of pain care sales, Jerry Eichhorn, was the “King of Pain” and signed memos simply as “King.”

“As you continue to carry the OxyContin banner onto the field of battle, it’s important to keep highlighting OxyContin benefits to your doctors,” Abbott urged its sales staff in a memo contained in the court records.

But some of the benefits the sales reps were instructed to highlight lacked scientific support, and in some cases were similar to claims made by Purdue.

In 2007, Purdue pleaded guilty to a criminal charge of misbranding OxyContin in an effort to mislead doctors and consumers. The company paid more than $600 million in fines.

A central charge in the US Department of Justice’s case was that Purdue “sales representatives falsely told some health care providers that OxyContin had less euphoric effect and less abuse potential than short-acting opioids.”

In an Abbott memo, sales staff were instructed that if a doctor was concerned about the euphoria a patient was experiencing on the shorter-acting painkiller Vicodin, they should tell the physician, “OxyContin has fewer such effects.”

In another memo — this one a listing of ideas to help sales personnel increase OxyContin’s share of pain-pill prescriptions written by orthopedic surgeons — Abbott told reps to highlight the “less abuse/addiction potential” of the drug, which could be taken just twice a day because of its time-release formulation.

Abbott reps were also given a graphic to show doctors that depicted levels of its pain-killing ingredient in the bloodstream holding steady, but it looked “flatter” than the levels actually were, according to the court records. The use of a similar graph was cited in the federal case against Purdue as a key part of evidence that it falsely marketed OxyContin as having less euphoric effects and abuse potential than shorter-acting opioids.

And a “coaching sheet” prepared for Abbott sales personnel advised discussing the potential abuse of OxyContin only if a doctor brought it up, and to tell physicians that “street users” were misusing the drug not “true pain patients.”

Lawyers for the state of West Virginia seized on the Abbott marketing materials as evidence the company misled doctors on the key issue of abuse.

“Abbott’s ‘King of Pain’ taught his ‘royal crusaders’ pseudoscience about OxyContin ‘minimizing the risk of dependence,’ and lowering euphoria,” they wrote in a motion unsealed as part of the STAT request. “However, the ‘selling sage’ turns out to have minimal knowledge of pharmacology, and admitted he had no basis to make these statements he passed along to his ‘royal crusaders.’”

Eichhorn, the Abbott official referred to as the “King of Pain,” did not respond to requests for comment. After overseeing OxyContin sales, he rose to become national marketing and sales director for Abbott. In 2013, when Abbott spun off its pharmaceutical operations into a new company called AbbVie, Eichhorn became national director of sales for the new company, a job he still holds.

‘Dine and Dash’ and other sales tactics

Abbott’s sales force missed no opportunity to gain access to busy doctors and get them to prescribe OxyContin, the court documents show.

One method was a program called “Dine and Dash.” Company sales reps would pay for takeout food at a restaurant favored by a particular doctor. During the five minutes that it typically took for the physician to pick up the food and the sales rep to pay for it, the Abbott employee would “detail” the doctor, according to an internal sales memo. Detailing is a pharmaceutical industry term for selling a doctor on the benefits of a drug.

A similar technique involved inviting a surgeon to a book store, giving the doctor a coupon, and then detailing the doctor while waiting to pay. In addition to bringing lunches to doctor’s offices, Abbott reps were encouraged to schedule afternoon cookie and candy snacks for those offices as a way to build goodwill with “appreciative” staff. Similarly, sales personnel were told to target nurses who were influential with doctors.

The creative tactics helped Abbott beat sales targets for OxyContin, earning “One-Eyed Jack lottery ticket rewards to all Crusaders” in 2000, according to a company sales memo. The tickets were worth up to $20,000, according to the document. Sales reps who achieved the greatest growth in market share were promised trips to “a location befitting a questing and conquering Crusader!”

The more Abbott generated in sales, the higher the reward for the company, as well. Under the agreement with Purdue, Abbott received 25 percent of all net sales, up to $10 million, for prescriptions written by doctors its sales reps called on, and 30 percent of sales above $10 million, according to court records. Purdue deducted an unspecified amount for costs related to items such as shipping and distribution.

Abbott refused to provide West Virginia’s lawyers figures showing its earnings from OxyContin, according to the court records, but documents obtained by the state in its lawsuit “show millions of dollars in earnings to Abbott.”

In a 1997 document, a company executive indicated that prescriptions written by “Abbott MD’s” comprised 25 percent of all OxyContin prescriptions. In addition, Purdue budget records obtained by the Florida attorney general reveal details of the payments to Abbott for its OxyContin work, which are termed “commissions.” From late 1996 through 2002, Abbott was paid about $374 million in commissions, according to those documents. Total sales of the drug during that time were nearly $5 billion.

From 2003 through 2006, after Abbott had stopped selling OxyContin, it still received a residual payment of 6 percent of net sales, according to the West Virginia court records. It is unclear whether that pertained only to prescriptions written by the Abbott doctors. OxyContin sales during that time were nearly $6 billion.

Purdue was not shy about pushing its bigger partner to be more aggressive in its sales efforts.

In a July 1997 memo, Purdue’s then-vice president Michael Friedman told seven members of the Sackler family who own Purdue, and other company executives, that the company had “been pressuring Abbott to increase their activity toward surgeons.” Friedman wrote that Abbott had responded with a “new emphasis on OxyContin and their dedication of significant resources to this task.”

In an attached letter from an Abbott executive to Purdue’s vice president of marketing, Abbott pledged to take the relationship between the companies to “new heights with our positioning of OxyContin as a key component of Abbott Pain Management.”

The sales forces of the companies worked in tandem. They held regular strategy sessions, alternating meeting locations between Purdue’s Stamford, Conn., headquarters and Abbott’s corporate offices in Illinois, according to the court records.

How Abbott stayed below the radar

The indemnification of legal costs proved to be a windfall for Abbott, and also saved it from unflattering publicity. When the West Virginia case was settled in 2004, the state made no mention of Abbott when the deal was announced.

Similarly, when Kentucky settled a lawsuit last year against Purdue and Abbott that alleged the companies misrepresented the addictive nature of OxyContin and caused doctors to overprescribe it, the state attorney general’s announcement left out Abbott. The case was settled by a $24 million payment from Purdue.

Abbott was frequently named a co-defendant in cases with Purdue over the alleged illegal marketing of OxyContin. In 2003, Abbott disclosed in its annual report that it was facing 306 pending lawsuits as a result of its OxyContin activities. But the company noted that “Purdue is required to indemnify Abbott in each lawsuit.”

A dispute between Purdue and its liability insurer offers a glimpse into the staggering legal costs associated with OxyContin litigation. By 2006, Purdue claimed $400 million in attorney fees and expenses for defending OxyContin cases.

An auditor hired by the insurer to review Purdue’s claims reported the drug maker paid more than 70 law firms to defend nearly 1,400 cases. The law firms billed for 1.2 million hours of work, according to the audit. Purdue’s insurer balked at paying the full amount and the parties eventually agreed to a confidential settlement. Those amounts do not include what Purdue paid to settle certain cases.

Purdue declined to comment on its indemnification agreement with Abbott or how much in legal costs it paid on its partner’s behalf.

The Abbott sales reps who devised the junk food ploy to win over the reluctant orthopedic surgeon were celebrated in an internal Abbott bulletin sent to the sales team nationwide. It was the grand prize winner of a contest soliciting the best OxyContin sales success stories.

They received 250 “TravPass dollars” as a reward, although the documents do not specify the real-world value of the prize or how the “dollars” could be used.

“We are pleased that we have such a sweet start in developing a relationship with this ‘no-see’ physician,” the Abbott sales reps wrote in the bulletin, “and we’re looking forward to sweet success with OxyContin!”