When a UNC Grad Student Confronted Dr. Ralph Snyderman for Aiding the Sacklers’ Opioid Scheme, the Duke University Professor Threatened Legal Action

Duke’s Press Office: “I can’t comment on Ralph Snyderman.”

8 minute read

Dr. Ralph Snyderman received what must have been a somewhat unpleasant and galling email last summer. A graduate student at the University of North Carolina, who was studying financial influence in medicine, had stumbled across a letter that Snyderman had published in the medical journal JAMA. That letter in JAMA, the graduate student emailed Dr. Snyderman, did not disclose the several boards he served on—including Purdue Pharma.

“The only affiliation I had that was relevant to the views expressed in the letter was disclosed—my position at the Duke Center for Research on Personalized Health Care,” Snyderman replied, while also accusing the student of the “false premise” that all affiliations must be disclosed. “I expect you will discuss this with your faculty advisor and that your final publication will reflect the corrections noted above. I would be happy to clarify any remaining issues.”

But Snyderman’s reply only invited more questions—questions that Snyderman has apparently sought to evade about his ties to Purdue pharma and the Sackler family that are found in a criminal complaint.

Except for a short break to work at Genentech in the 1980’s, Snyderman has been on faculty at Duke University since the early 1970’s. He later served as Chancellor for Health Affairs and Dean of the School of Medicine from 1989 to 2004, and became the first president and CEO of the Duke University Health System. Today, Duke’s medical school ranks third in the nation for research.

In 2014, a business paper in North Carolina reported that Duke paid Snyderman $7 million—the highest compensation for anyone at Duke. “For the first time in recent memory, Duke University head basketball coach Mike Krzyzewski was not the university’s highest paid employee,” the paper wrote.

In short, Snyderman is kind of a big deal at Duke.

Now the Director of the Duke Center for Personalized Health Care, the university touts Snyderman as a national leader on precision medicine, and he has been praised for advocating that physicians engage with patients to improve their health. After he co-authored a medical journal article on compassion in healthcare with the Dalai Lama, North Carolina Public Radio narrated a glowing review, with Snyderman admonishing that compassionate medicine is difficult to achieve in the United States.

Ralph Snyderman speaking with the Dalai Lama.

“His mission is to create more personalized and compassionate ways of delivering medicine,” North Carolina Public Radio reported.

But all these career accolades became minor historical footnotes when Dr. Snyderman received a second email last summer from that same UNC graduate student—Alex Rich. Unlike most graduate students, Rich is not some young kid, frightened that he might annoy an elite, wealthy, and powerful member of academic medicine. Before heading to UNC graduate school, he had already spent over a decade as an officer in the United States Air Force, flying air support for Special Operations soldiers in combat.

To be clear: gods of medicine do not spook Rich.

In a multi-page email, Rich asked Snyderman to clarify his board membership with two organizations: one was an obscure firm involved in insurance; the second was Purdue Pharma, the company charged with starting an opioid epidemic that has killed hundreds of thousands of Americans.

“As a member of the Board of Directors of Purdue Pharmaceuticals from August 2012 to October 2017, you oversaw a company engaged in criminal conduct to which the company has since pleaded guilty,” Rich wrote. He then provided a link to the Justice Department’s announcement that Purdue had plead guilty to conspiracies to defraud the United States and had paid kickbacks to doctors.

Two days later, Snyderman responded, this time looping in Javed Mostafa, the head of Rich’s graduate program at UNC. “This will be my final communication with you. You are playing with people’s reputations by communicating allegations that are false,” Snyderman wrote. He then refuted the mention of his ties to the insurance firm and accused Rich of defamation for writing that he had known of Purdue’s criminal activity.

“If you write something that suggests that I had any knowledge whatsoever of criminal activity at Purdue while I was on the board, or if you otherwise continue to engage in defamatory activity against me, you will hear from my lawyer as will the academic standards office at UNC,” Snyderman wrote.

This blunt email ended all communications.

Shortly after Christmas, Rich contacted me about his correspondence with Snyderman, later providing all of their emails. Rich also sent other supporting documents, including his emails with Dr. Phil Fontanarosa, JAMA’s executive editor. (Note: Dr. Snyderman has not responded to multiple emails asking for comment regarding his publication in JAMA, his communications with Alex Rich, nor the charges alleged against him by several state Attorneys General.)

“The obvious inadequacy of the Purdue Pharma bankruptcy settlement, particularly the Sackler family's success in evading criminal charges, makes imperative the fullest possible disclosure of documents from the legal proceedings so that we can learn more about people like Dr. Snyderman,” said Kathleen Frydl, an historian of America’s drug crises and author of “The Drug Wars in America, 1940-1973.” She added, “Without that accountability, it's impossible to identify failures in how medical expertise is recognized and vetted.

---

Studying financial influence in medicine

As part of his graduate work, Rich developed an algorithm to study payments from industry to physicians. While analyzing this data last year, to see where companies were paying doctors, he noticed something unusual. “I was geocoding and visualizing payments, and I saw a huge circle over Durham, North Carolina, where Duke is located.”

As he was trying to understand why companies were lavishing payments on physicians living around Duke, Rich discovered that Purdue had paid Snyderman several hundred thousand dollars. He then found a 2016 letter that Snyderman sent to JAMA, in which Snyderman argued that current healthcare policy needed to change. Digging through corporate filings, Rich then discovered that Snyderman sat on the board, of not just Purdue, but several other healthcare companies as well.

Neither Purdue Pharma nor these other companies were disclosed in Snyderman’s JAMA letter.

“He was pontificating on how the United States should run this incredibly expensive federal healthcare system,” Rich said. “Shouldn’t he have to disclose those companies?”

Rich then emailed JAMA’s Fontanarosa to see if the journal required Snyderman to disclose corporate board memberships. Fontanarosa provided a short response, before directing Rich to contact Snyderman. “[D]id you already contact Dr Snyderman about this issue to obtain clarification before your publication?” Fontanarosa replied. (Note: Dr. Fontanarosa has not responded to multiple emails asking for comment regarding Dr. Snyderman’s publication in JAMA, nor his interactions with Alex Rich.)

Rich then sent Fontanarosa additional information about Snyderman’s financial interests back in 2016—information that he felt deserved to be disclosed. For example, the year after Snyderman’s letter in JAMA, iRythym Technologies reported to the Securities and Exchange Commission (SEC) that they had elected Snyderman to their board and that he also was serving on the boards of a handful of other companies, as well as Purdue Pharma.

Rich also asked Fontanarosa several questions he hoped would clarify JAMA’s policies that require authors to disclose their financial ties. “I will contact Dr. Snyderman for clarification prior to publishing,” Rich wrote. “My hope is to first understand JAMA's perspective on situations like this.”

Fontanarosa later followed up with answers to Rich’s questions. In one example, Fontanarosa explained, “Board memberships of biomedical companies, particularly if the entity is relevant to the subject matter of the article, would ordinarily be expected to be included in author disclosures.” Fontanarosa then advised Rich, “If you would be willing to share with us the information you receive when you contact Dr Snyderman (provided Dr Snyderman agrees that you can share that information), it may be helpful in our evaluation.”

Fontanarosa was then looped in on the emails between Rich and Snyderman, including the final one, in which Snyderman denied any knowledge of Purdue’s illegal behavior, and then threatened Rich with legal action and notification of officials at UNC

Odd final response

This final response by Snyderman seems odd and misplaced.

Snyderman’s board membership at Purdue is public knowledge and has been reported on by several media outlets. On January 31, 2019, Massachusetts’ Attorney General Maura Healey filed a complaint against the Sackler family claiming that they should be held personally liable for Purdue’s actions. This complaint named several members of Purdue’s board, including Ralph Snyderman. Snyderman was later named in stories that covered this lawsuit, including Boston’s NPR station WBUR and the Financial Times.

Three months after the Massachusetts complaint, Connecticut Attorney General William Tong named Snyderman and other Purdue board members as defendants in another lawsuit against the Sacklers. The Daily Mail later named Ralph Snyderman in their report on this lawsuit.

By the time these lawsuits were filed and reported on in 2019, Snyderman had already left Purdue’s board. But the timing of Snyderman’s split from Purdue is rather interesting.

During the summer of 2017, reporter Christopher Glazek contacted me about an investigative feature he was writing for Esquire on the Sacklers. “The emphasis of the piece is on the family itself, but I'd like to include a substantial discussion of the various front organizations Purdue uses [to] shape the political discourse surrounding prescription opiates,” Glazek wrote in July 2017.

Glazek’s piece titled, “The Secretive Family Making Billions From the Opioid Crisis,” appeared on Esquire’s website on October 16, 2017. According to a court statement later signed by Snyderman, he left Purdue’s board two weeks after this date, on October 30, 2017.

As for the claims of criminal activity by Snyderman? These seem to have disappeared in court filings that remain sealed. In her 2019 complaint, Massachusetts’ Attorney General Maura Healey made multiple charges against the Sacklers as well as against Snyderman and other Purdue board members. “Defendants Peter Boer, Judith Lewent, Cecil Pickett, Paulo Costa, and Ralph Snyderman took seats on the Board and knowingly advanced the Sacklers’ scheme.”

The complaint runs 274 pages, with detailed charges against Snyderman and other board members on pages 173-196. “Together with the Sacklers, they controlled the unfair and deceptive sales and marketing tactics Purdue used to sell its opioids in Massachusetts.”

According to the complaint, Snyderman voted with the Sacklers to hire hundreds more sales reps to sell opioids; to implement incentive compensation policies that aggressively drove opioid sales; and, to pay out millions of dollars to convicted criminals Michael Friedman and Howard Udell to help the Sacklers keep their loyalty.

The Massachusetts complaint states that, shortly after Snyderman joined Purdue’s board in 2012, Purdue’s staff briefed board members about a confidential Purdue study:

In November, staff provided Boer, Lewent, Pickett, Costa, and Snyderman with the confidential results of a study of 57,000 patients that Purdue performed explicitly to determine how opioid dose “influences patient length of therapy.” The results showed patients on the highest doses stay on opioids longer. The “Recommended Actions” for included “additional workshops for the sales force” and “specific direction” to the sales representatives about using higher doses to keep patients on drugs longer. Staff told Lewent, Pickett, Costa, and Snyderman, together with the Sacklers, that encouraging higher doses “is a focal point of our promotion,” and that sales reps would “emphasize the importance” of increasing patients’ opioid doses, as soon as 3 days after starting treatment.

Some months after Massachusetts filed their complaint, Snyderman and the other Purdue board members sought to have it dismissed for overreach. “Because the Outside Directors are not alleged to have done anything other than serve as board members of the Purdue Defendants, the claims against them should be dismissed with prejudice,” the defendants wrote to the court.

Judge Janet L. Sanders denied this motion in November 2019, stating that the complaint against the board members was sufficient to satisfy a legal rule that each board member personally participated in wrongdoing and that claims to the contrary were unpersuasive. “Moreover, because opioids such as Oxycontin are highly addictive drugs,” the judge wrote, “a fact finder could plausibly conclude that the defendants knew that misleading and deceptive efforts to increase the prescription of these drugs at higher doses and over longer periods would foreseeably lead to increased addiction and its attendant consequences.”

At this point, the legal trail involving Snyderman and the other board members seems to disappear.

A year after Judge Sander’s ruling, in November 2020, Purdue pleaded guilty in federal court to several felonies, admitting that it marketed and sold dangerous opioid products, lied to the Drug Enforcement Administration about steps it had taken to prevent the diversion of opioids, and that it paid kickbacks to encourage prescribing.

Last July, Massachusetts Attorney General Maura Healey announced a resolution with Purdue Pharma and the Sackler family involving their role in the opioid crisis. Purdue agreed to make a $4.3 billion payment for opioid treatment in cities across the country and to make public tens of millions of documents disclosing their role in the epidemic. This settlement remains unresolved and those tens of millions of Purdue documents remain hidden from public scrutiny.

“Low level drug dealers wind up in jail, while the Sacklers walk away billionaires and Snyderman remains prominent and respected,” said Dr. Andrew Kolodny, medical director of the opioid policy research collaborative at Brandeis University. “Convicting a corporation of a crime is meaningless and fines can be seen as the cost of doing business.  If we want to deter corporations from killing people in their pursuit of profit, the individuals who called these shots must be held accountable.”

In an email to Duke University, I explained the legal complaints made against Snyderman and described Snyderman’s emails with graduate student Alex Rich. I then asked the university several questions: Is Duke looking into Snyderman’s behavior while on Purdue’s board? Does Duke feel Purdue Pharma officials should be held accountable for the opioid epidemic? Is Duke involved in the litigation that has ensnared Snyderman? And, does Duke support research, like Alex Rich’s, examining financial influence in medicine?

Duke assistant vice president for media relations, Erin Duggan Kramer, replied by email that she was confused about what was being asked of Duke. I then repeated my request for answers to the questions I had sent. I added that the Sacklers are seeking to have themselves and board members shielded from any future civil litigation, as part of a settlement in bankruptcy court.

“Is Ralph Snyderman one of the people seeking release from any future civil liability for the actions of Purdue and the Sacklers in fueling the opioid epidemic?” I asked.

 “I can’t comment on Ralph Snyderman,” Erin Dugan Kramer replied. “I’ll decline comment.”

“This is the ‘father of precision medicine’ being accused by State Attorneys General of overseeing the precise targeting of vulnerable patients with dangerous doses of opioids,” Rich said. “That can’t stay hidden.” He added that Duke has failed to address this matter and continues to bring young, optimistic new medical students to campus where they might be mentored by Snyderman.

“Duke University’s persistent silence on this topic is a huge problem.”

This commentary has been co-published by The DisInformation Chronicle and The Journal of Scientific Practice and Integrity (JoSPI).