While there have been several books written on the influences and factors that brought America to its current struggles with opioids, the 2021 book by Patrick Radden Keefe is arguably the most thorough. His book, published in April, is titled Empire of Pain: The Secret History of the Sackler Dynasty.
Mr. Keefe reaches back to 1913 and the birth of Arthur Sackler, the author of the aggressive marketing paradigm that launched the family’s riches. He pioneered the marketing messages that sent Valium into the medicine chests of millions of Americans. It took years for the addictiveness of this drug to be unearthed. But Arthur had already banked his profits.
From this modest start, the tendrils of the Sackler family’s power wound around the pharmaceutical industry like the relentless twining of vines around the trunk of a massive tree. By 1950, Arthur and his brothers Raymond and Mortimer had all become doctors. In 1952, the brothers purchased a small pharmaceutical company known mostly for laxatives and disinfectants. That company was Purdue Frederick. This was the forerunner of the company that would develop and market OxyContin, Purdue Pharma.
Purdue Frederick, along with other business ventures, continued to make the family rich while the three brothers married and had children. One of those children, Richard Sackler, was to become a pivotal character in the opioid epidemic that was to sweep America.
Entering the Opioid Market
In 1966, the Sackler brothers purchased another small pharmaceutical company, Napp Laboratories in England. One of their scientists at Napp developed a groundbreaking form of the opioid painkiller morphine. Whereas morphine had always needed to be administered via injection, this new formulation was a time-release pill that would deliver pain relief slowly. Finally, patients could take pills home instead of needing shots or drips of morphine. This pill was called MS Contin and it was released in the UK in 1980.
As the Sacklers and Purdue Frederick made plans to market the drug in America, they needed to devise a way to circumvent the restrictions placed on new drugs by the Food and Drug Administration. They did so using a method advised by one of their primary lawyers: simply begin making and marketing the drug without asking permission.
Three months later when the FDA began insisting that Purdue receive FDA approval for their new drug, cancer patients across the country were already relying on this new pill to relieve their pain. Purdue executives and lawyers simply went over the FDA’s head to the White House to relieve the pressure.
And thus their methodology of succeeding in selling their drugs, addictive or not, legal or not, was born.
“You won’t believe how committed I am to make OxyContin a huge success. It is almost that I dedicated my life to it,” Richard Sacker wrote to a friend as this drug was being developed. He followed this dedication with an unprecedented tsunami of marketing pressure and innovation gimmicks to get the drug being prescribed in unfathomable quantities.
Under his direction, Purdue Pharma hired doctors to claim that OxyContin was suitable for long-term use for non-cancer pain. The company paid to have authoritative articles written about how “pain was undertreated” to encourage doctors to prescribe more opioids. Sales reps were taught to downplay any possibility of addiction in patients treated for pain. Purdue funded the establishment of multiple consumer pain organizations that supposedly supported the efforts of pain patients to get the medication that would wipe out their suffering. The country was awash in paid propaganda about the safety of this drug. But every bit of it was a lie.
As reported extensively by Keefe, Richard Sackler has never manifested concern for problems like addiction or overdose caused by his drug. Not then and not after hundreds of thousands of American deaths due to opioid overdoses. I found it interesting that the book notes that even Sackler’s college roommate commented that the man seemed to lack empathy.
Where was the Food and Drug Administration when they were supposed to be protecting the American public? Their official in charge of approving drugs like OxyContin, Curtis Wright, was being wined and dined by Purdue. Keefe reports that “the team from Purdue spent several days helping Wright compose the reviews of clinical study reports and the integrated summaries of the efficacy and safety of their own drug.” Despite there being no trials or investigation of whether or not this drug was subject to abuse or likely to cause addiction, it was approved for sale in December 1995. Not long after, Curtis Wright took a high-paying job with Purdue Pharma.
After this approval, Purdue held a festive launch party for this drug in a Phoenix resort. In the midst of tables full of party food and rivers of alcohol, Richard predicted that the “launch of OxyContin tablets will be followed by a blizzard of prescriptions that will bury the competition.”
Sales reps were pressured relentlessly and the pressure came from the top, from Richard Sackler’s mania about OxyContin. Doctors who were likely to prescribe indiscriminately were targeted for special visits. Attractive awards and trips to resorts were offered to entice prescribers to switch from some other painkiller to OxyContin.
That Was Just the Start
This pressure kept up, according to Keefe, even as the company received word that the pills were easy to abuse, even as they heard about overdoses. Finally, by 2007, there was enough evidence amassed for federal prosecutors to file a lawsuit in Virginia to try to stop the fraudulent marketing. The company settled this lawsuit for $634.5 million. The three executives who took the heat for the past fraud and “misbranding” left the company. Other representatives of the company promised to change their tactics. But they didn’t.
It took another dozen years and thousands of lawsuits from nearly every state plus counties, cities, tribes, unions and hospitals to bring a halt to the company’s tactics. Even now, the end of the tale has not yet been told, as Purdue and the Sacklers march through bankruptcy court with a long list of promises about how they will benefit the public henceforth.
What Was Purdue’s Responsibility?
There’s no way to convey in this short review the mountains of evidence that have been collected and released about the involvement of Purdue in the overprescribing of opioid painkillers, drugs that every fledgling doctor should have known had addictive potential.
As documented in publicly released papers and compiled by Mr. Keefe, every government agency that tried to curb its ability to wreak the resulting opioid disaster failed. Either because they were compromised or because some senior official tied their hands.
Keefe traces the entirety of the OxyContin saga, starting at the very beginnings of the Sacker family involvement in pharmaceuticals and ending in the bankruptcy proceedings of Purdue Pharma. He documents every fact he presents in more than 50 pages of small-type citations directing the reader to the exact source of each statement.
It is up to the reader to decide for themselves if the launch of OxyContin was also the launch of America’s opioid catastrophe. There is plenty of evidence in this book to enable a reader to make this decision. I would only hope that every family in America that has lost someone to OxyContin or an opioid overdose has access to the information in this book. I hope that every doctor who lost a patient to painkillers because they believed pharmaceutical sales reps over their medical training learns this information.
It’s a long book, more than 430 pages. And the information presented is daunting. But it’s an important lesson in how essential vigilance and integrity are in protecting the welfare of our families, communities and our country. Without them, we get to the painful point we find ourselves at today, where more than 100,000 Americans are dying of drug overdoses each year.
Of course, there are many other major factors at play in this overdose number, most prominently the arrival of copious amounts of fentanyl in our drug supplies. But would we have ever gotten into this situation without that initial pressure to create a “blizzard of prescriptions”? For that answer, you must read this book and make up your own mind.