The opioid epidemic has killed nearly half a million Americans over the past two decades. Many of their loved ones, along with public health advocates and experts, believe that one very rich, very famous family has never fully faced the consequences for its role in those deaths. “Empire of Pain,” the explosive new book by journalist Patrick Radden Keefe, is an attempt to change that — to hold the family accountable in a way that nobody has quite done before, by telling its story as the saga of a dynasty driven by arrogance, avarice and indifference to mass suffering.
The family is the Sacklers, who until a few years ago most people knew only as the benefactors of universities and museums, including a Smithsonian gallery named for Arthur M. Sackler. But the clan, which made its fortune in the pharmaceutical business, was also the money and power behind Purdue Pharma, the maker of OxyContin, a potentially addictive pain medication that has played a key role in the opioid crisis. The Sacklers and their legal representatives have long challenged reports suggesting that they deliberately downplayed Oxycontin’s dangers or otherwise bear some responsibility for the epidemic. Among those reports was a 2017 article by Keefe in the New Yorker, where he is a staff writer. The magazine stood by the article following an internal review.
Keefe says the Sacklers did not cooperate in the writing of his book. As he explains, in his final attempt to get answers from the Sacklers, he sent a lengthy memo of queries, by request, to a family lawyer. A brief, one-and-a-half-page response claimed that Keefe’s questions were “replete with erroneous assertions built on false premises” — and declined to answer them specifically.
In “Empire of Pain,” Keefe marshals a large pile of evidence and deploys it with prosecutorial precision. Some of the material comes from other journalists — among them Barry Meier, author of the acclaimed 2003 book “Pain Killer: A ‘Wonder’ Drug’s Trail of Addiction and Death,” who is also a key character in Keefe’s story. The rest comes from Keefe’s own reporting, which included interviews with more than 200 people, access to internal company documents, and a review of tens of thousands of pages of court documents that public and private lawyers collected in the course of their investigations and lawsuits.
Purdue introduced OxyContin in the late 1990s, at a moment when the medical profession was seeking better ways to alleviate pain, which it had been neglecting. A central problem for generations was that the most effective drugs were prone to cause addiction. Enter OxyContin, a hard-shelled pill that released its powerful medication slowly and steadily, thus avoiding the peaks and troughs of pain relief that can foster addiction.
Or at least that was the sales pitch. In reality, people figured out pretty quickly how to extract the opioid substance, usually by crushing the pill’s shell. Then they would ingest it, frequently by snorting, and get a quick high. From there, people would sometimes move on to illicit drugs like heroin and, in too many cases, fatal overdoses.
Addiction is a complex phenomenon with many causes. And OxyContin, which is still prescribed and considered effective under the right circumstances, was not the only medication that sometimes became the basis of addiction. But it was the first of a new generation and, according to a wide array of experts, occupied a unique role in the plague that followed. “The introduction and marketing of Oxycontin explain a substantial share of the overdose deaths over the last two decades,” one group of economists concluded, based on a study that compared drug prescription patterns across states.
One of the book’s most revealing episodes is from 1999, as the first stories of OxyContin addiction were spreading, when a Purdue corporate officer asked his legal assistant to enter online chat rooms under a pseudonym and learn how people might be abusing the drug. She discovered the stories of crushing and snorting, Keefe writes, and put it all in a memo that Purdue later denied having but whose existence a Justice Department investigation subsequently confirmed.
The twist in the story is that the legal assistant ended up taking OxyContin for back pain, at her boss’s suggestion, and got addicted by using some of the same methods she’d investigated. Her work performance suffered, and Purdue fired her after 21 years with the company. She later sued, but the legal action went nowhere, Keefe reports, because the company subpoenaed her old medical records to show that she had struggled with addiction before.
It was a few years after her memo circulated, in 2007, that federal prosecutors first went after Purdue, winning what seemed at the time to be a significant victory. One of the company divisions pleaded guilty to “misbranding” OxyContin, while three top executives pleaded guilty to individual misdemeanor versions of the same crime. Purdue also agreed not to contest an official fact-finding document detailing the company’s marketing methods, which management designed specifically to overcome physician fears about addiction.
But neither the fine nor the pleas did much to change company behavior, according to Keefe. Instead, he writes, company officials saw the penalties as a “speeding ticket.” They continued to sell the drug using many of the same methods as before, such as distributing literature claiming that it was less prone to cause addiction than other, older pain medications. They continued to supply providers who, Keefe writes, the company knew from its sales data were almost certainly overprescribing.
As for the Sacklers themselves, they were not among the executives who faced charges. And as the body count grew, family members insisted that the problem was the people getting addicted, not the drug or Purdue’s marketing of it. Keefe quotes Richard Sackler, who at the time was the company’s president, telling colleagues that “these are criminals, why should they be entitled to our sympathies?” Years later, in a subsequent court case related to the epidemic, Richard Sackler admitted under oath that he had never bothered to read the entire 2007 fact-finding document that prosecutors had hoped would serve as the basis for guiding Purdue’s future behavior.
Richard is a nephew of physician and family patriarch Arthur Sackler, who in family lore was dedicated to the betterment of humankind but who, in Keefe’s account, comes off rather less charitably.
Although Arthur was good at practicing medicine, he was even better at marketing and got a part-time gig, alongside his clinical duties, working at an advertising firm that handled drug company accounts. Two years later, he was the firm’s president and on his way to pioneering many of the techniques we now associate with pharmaceutical sales, such as courting physicians with free meals and creating “native advertising” that looked like independent editorial content. “Arthur invented the wheel,” as one former employee at the advertising agency put it.
One of Sackler’s big accounts was for the drugmaker Roche and its then-new tranquilizers, Librium and Valium, which the advertising company and its Sackler-produced promotion campaign said were not addictive — although, in many cases, they turned out to be just that. Congressional investigations followed, and eventually tougher regulation of the drugs, though not before revenue from the advertising contract (which rose in tandem with sales) vaulted Arthur Sackler into the upper echelons of American wealth.
“The original House of Sackler was built on Valium,” Keefe writes. But for the rest of his life, Sackler “would downplay his association with the drug,” especially as he and later his family became such prominent patrons of the arts and higher learning. “On the rare occasion when he did address the ravages of Valium,” Keefe writes, “he would echo the sentiment of his clients at Roche. . . . It wasn’t the pills that were getting people addicted; it was the addictive personalities.”
Arthur’s two younger brothers, Mortimer and Raymond, also became physicians. And although they were less academically accomplished than Arthur, they shared their brother’s fascination with pharmacology. Eventually, he purchased Purdue for them to run.
How Purdue came to be theirs and how it then came under the direction of Raymond’s son Richard is one of many contorted tales of family conflict that can occasionally be difficult to follow. But Keefe is a gifted storyteller who excels at capturing personalities, which is no small thing given that the Sacklers didn’t provide access.
One place the family’s behavior is especially revealing is near the book’s end, with private lawsuits and public prosecutions finally pushing Purdue into bankruptcy — and with damaging media coverage sullying the Sackler family name, to the point where universities and museums were scrambling to erase the word “Sackler” from their titles and edifices.
At one point, Keefe recounts, a family member circulated an anxious email because she’d heard about an upcoming segment on the HBO show “Last Week Tonight With John Oliver,” which her son and his friends watched religiously. “This situation is destroying our work, our friendships, our reputation and our ability to function in society. . . . How is my son supposed to apply to high school in September?”
Of course, hardship is relative. Even after the bankruptcy and shaming, Keefe writes, the Sacklers largely held onto their money, because they had extracted most of their fortune from the company and placed it in private holdings. They never faced criminal charges, even though many prosecutors wanted to bring them.
During the bankruptcy hearings, several family members of the deceased tried to speak, apparently hoping for closure. Among them was a woman who lost her brother: “He was my last family member, and my entire family has been affected through this epidemic, and through Purdue Pharma’s family. So I really would like to speak from the pain that it has created and me being left behind with no family.”
She didn’t get to make her speech. The judge said it was inappropriate for the forum. But the story lives on in Keefe’s book — juxtaposed, as it should be, with that of the Sacklers.
Empire of Pain
The Secret History of the Sackler Dynasty
By Patrick Radden Keefe
Doubleday. 535 pp. $32.50