Yesterday I decided to binge on the two part HBO series “The Crime of the Century.” It detailed the horrors inflicted on the most vulnerable of the American people – individuals who suffer from chronic pain or are about to pass away and are in extreme pain. The culprit for these horrors was and remains the Sackler family and its company Purdue Pharma which was created when its other pharmaceutical company Purdue Frederick was making a great deal of money manufacturing items like Benedine and Senekot, but for the family led by Richard Sackler this did not produce enough profit, so it branched out into the “pain market” and took one of its products MS Contin and reoriented its composition to create Oxycontin. The process involved pressure on the FDA, a great deal of obfuscation concerning its components, bribery, and outright lies to cause the death of over 500,000 Americans since its release in 1996. One of the narrators for the documentary was Patrick Radden Keefe, a staff writer at The New Yorker and the author of the New York Times bestseller, SAY NOTHING: A TRUE STORY OF MURDER AND MEMORY IN NORTHERN IRELAND the winner of the 2019 National Critics Circle Award for Nonfiction. Keefe’s newest book EMPIRE OF PAIN: THE SECRET HISTORY OF THE SACKLER DYNASTY fills in some of the gaps of the HBO expose and reaffirms the despicable actions of numerous characters in the family, Purdue Pharma employees, and individuals outside the company and family who were coopted into the process because of greed and a convoluted sense of morality.
EMPIRE OF PAIN is a multi-faceted biography of a family dynamic that produced individuals who seemed to lack empathy for others and were obsessed with the accumulation of wealth which allowed them to satisfy their pocketbooks and egos. Secondly, it is a study that delves into the drug empire created by the Sackler family and the lengths they would go to continue to engage in practices that would enhance and maintain their wealth while ignoring the negative and at times disastrous effects of their decisions on the American people. Some family members would argue that this accumulation of wealth is partially offset by the philanthropic ventures that the Sackler’s pursued. The name Arthur M. Sackler, the individual most responsible for beginning the creation of its “pain empire” appears on museum walls and buildings ranging from New York’s Metropolitan Museum of Art, the Smithsonian in Washington, D.C., Harvard, Tufts, Columbia Universities, the Sackler School of Medicine in Tel Aviv, among others in London, Paris, and Berlin. These gifts and/or donations were made possible by the fortune earned from developing and marketing drugs like Librium and valium in the 1960s and 70s with its negative effects on those patients whose doctors over prescribed the medication.
Keefe’s narrative unfolds as he explores the origins of Sackler family wealth which is estimated at about $14 billion. He delves into the role played by three brothers; Arthur, Raymond, and Mortimer Sackler, all three physicians who developed the edifice that resulted in the hundreds of thousands of drug overdoses that have been inflicted on American society in the last few decades. The key figure is Arthur M. Sackler who after working at Creedmoor Mental Hospital in New York along with his brothers in the 1960s concluded that the care for the mentally ill was grisly and became convinced there was a better treatment solution. Arthur Sackler, trained as a Freudian concluded that one’s life experience could not fully account for mental illness – that there was a chemical component, and he would unlock the mystery to help these people. Sackler would conclude that the derangement of brain chemistry was the missing link. The brothers conducted a series of experiments on rabbits which reinforced their views of chemical changes in the brain being responsible for mental illness.
Keefe lays out the early careers of the brothers, but Arthur was the key. He was a complicated individual who enjoyed multiple careers; physician, mental illness researcher, and advertising executive. His strategy was to market products/medicines directly to doctors and at first took “broad spectrum anti-biotics” and revolutionized medical marketing by convincing physicians to write prescriptions for his products. The advertising techniques used for clothing, automobiles, food, perfume etc. were now applied to medicine. Promotion and brand differentiation were key, and Arthur’s success was built upon his purchase of the William Douglas McAdams advertising agency whose major client was Pfizer.
As Keefe points out, Arthur was shrewd as he owned or had a partnership with McAdams and Bill Frohlich’s ad agency. The brothers opened their medical practice in the 1950s in New York and purchased Purdue Frederick, a small company in the patent medicine business. The expansion of their wealth was predicated on developing what they termed “a minor tranquilizer” to offset the use of Thorazine. Roche, another major pharmaceutical company developed Librium to meet that market and Arthur was tasked to market the new drug. In an age of Cold War anxiety, it was the perfect time to launch a new tranquilizer. By 1963 Roche would build upon Librium and develop Valium and Arthur’s firm zeroed in on convincing doctors that it worked separately on anxiety, muscle tension and numerous other ailments. It would become the first $100 million drug in history, further little was done to determine if the new drugs were addictive – creating a Sackler family pattern. Valium would be used by 20 million Americans and was at that time the most widely consumed and abused drug in history. Even the Rolling Stones wrote a song about Valium, “Mother’s Little Helper.”
Keefe encapsulates Arthur’s approach carefully correctly arguing that “he desired posterity, not publicity. The last thing Arthur wanted to do was call attention to his own wealth and holdings, and to do so in a manner that might raise questions about his overlapping careers.” It was quite clear that Arthur modus vivendi of helping develop drugs, fiercely marketing them to physicians, manipulating the FDA through the likes of Dr. Henry Welch, indirect gifts and bribery to the right individuals be they salespeople or doctors was unethical as well as illegal.
(Cheryl Juaire, center, of Marlborough, Massachusetts, center, leads protesters near the Arthur M Sackler Museum at Harvard University)
As Keefe lays out his arguments it is clear the groundwork for our current drug problem was fostered by the Sackler brothers approach that drugs are not addictive, and it was the patient’s personality and needs that were responsible not the drug manufacturer or the physician. It was clear as they marketed Valium they developed the advertising approach designed to create a vast market for Oxycontin.
The main culprit among the next generation of Sackler’s was Raymond’s son Richard, and Arthur’s daughter Elizabeth (Kathe). The family created a new company, Purdue Pharma to engage in developing a “pain” product that would create a new market since their patent for MS Contin, a morphine based drug was running out. The Contin process contained a time released component over a twelve hour period that they argued would prevent addiction. Kathe’s goal was to apply the Contin system to Oxycodone and Richard would micromanage its development. At first, they stressed that the new drug Oxycontin (time released Oxycodone/morphine) should be marketed just for cancer patients to gain FDA approval, but what was never mentioned was that Oxycodone was synthesized into heroine by Bayer in Germany. Once on the market for a period of time the target market would be expanded.
Keefe does an excellent job recounting the mindset of Richard Sackler and his cohorts in undoing the perception that Oxycontin was addictive to enhance the profitability of the drug. This approach was implemented with a vengeance. Mitchell Freidman who had been Head of Marketing at the FDA joined Purdue Pharma a year after he left the government and he and Richard would spearhead the idea that Oxycontin could be used for a myriad of issues from back pain, arthritis, post-surgical pain etc. Keene has culled the evidence and shows how Richard and Freidman deliberately chose a marketing strategy to deceive doctors and their patients of the low addictive quality of Oxycontin and the mistaken belief held by doctors that the drug was less powerful than morphine. Curtis Wright, who oversaw pain medication at the FDA, was cultivated and he helped write the drug insert for the medication that stated, “Delayed absorption, as provided by Oxycontin tablets, is believed to reduce the abuse liability of the drug.” On December 28, 1995 the FDA approved Oxycontin. A year later Wright earned $400,000 at Purdue Pharma.
The sales approach described by Keefe to market the new drug rested on the company’s catechism, “the delivery system is believed to reduce the abuse liability of the drug.” Keefe dissects the sales pitch and training of the hundreds of Pharma reps. They would target certain geographical areas like southern West Virginia and eastern Virginia and the rust belt to maximize sales as people overdosed.
Keefe’s account is stunning and based on assiduous research, confidential and original documents, and interviews. The author follows the legal battle to unearth what the Sackler’s had done and its vast implications for the wealth and health of the American people. Their arrogance is clear in the words of Kathe Sackler who boasted that Oxycontin was “very good medicine” and “a safe medicine.” She also claims credit for coming up with the “idea.” Years later in reference to the hundreds of thousands of addicted Americans she claimed not be aware of that. In 2007 the Bush Justice Department only delivered a slap on the wrist after investigating Purdue Pharma. It was no coincidence that the Sackler’s were major donors to the Republican Party and Rudy Giuliani was one of their lawyers!
The name Barry Meier, a New York Times reporter and author of the first major expose dealing with Purdue Pharma and the Sackler’s, PAIN KILLER: AN EMPIRE OF DECEIT AND THE ORIGIN OF AMERICA’S OPIOID EPIDEMIC became a thorn in the side of the opioid industry. Keefe relies on Meier’s early work in his research and conveys the travails that the reporter had to deal with. Purdue Pharma executives pressured the Times to block Meier’s efforts. They were successful for a period of time until the various trials against the corporation took place where he was “reinstated” on the topic and his incisive reporting reemerged.
Keefe and Meier argued that it is clear that Purdue Pharma had an inside man at the FDA and Paul McNulty, the deputy attorney general during the Bush administration handcuffed the prosecution and the efforts of John Brownlee, the federal prosecutor for the western district of Virginia who went after Purdue Pharma. In 2007 Purdue would pay a $600 million fine for the $35 billion earned from Oxycontin. Two years ago, when the Sackler’s faced their harshest legal challenge, they sold their stake in Purdue Pharma, moved their money overseas and had Purdue file for bankruptcy. Once that strategy was implemented, no court could gain damages from the family’s personal funds. By 2019-20 the Trump Justice Department under William Barr gave the family a reprieve and no family members or company executives would face criminal charges.
Keefe effectively traces how finally after 2013 the Sackler family name became toxic as museums, universities, medical schools, and hospitals refused their donations and, in some cases, removed their names from their properties. Keefe follows the family’s efforts to counter lawsuits brought by numerous state Attorneys General and their use of White Plains, NY Judge Robert D. Drain to protect the Sackler family wealth, in addition to the family realization that for the first time settlements might hit them personally. As a result, they began to siphon off vast amounts of cash (family wealth is estimated to be $14 billion) from the company and planting it in offshore accounts. The result is that this entitled group of “Sackler’s” had to face the fact they had become social pariahs.
Samanth Subramanian’s review of May 13, 2021, in The Guardian sums up the devastation and corruption, both government and non-government very clearly and its implications for the future: Keefe’s narrative is so lush with details that only in the chinks do we spot the story behind the story: the rotting structure of American healthcare that almost wills disasters into being. Some failures are born of lethargy or neglect. A federal government official once told me that if states had simply transitioned faster to reporting their health statistics electronically, someone might have caught a pattern: “all the drug overdose deaths, the suicides, the medical examiner events” that advertised the opioid crisis. But other failures are the results of a system maintained at a level of designed corruption.