Book Review — Empire of Pain by Patrick Radden Keefe

Yesterday evening, I finished Empire of Pain: The Secret History of the Sackler Dynasty by Patrick Radden Keefe. Keefe is an American writer and investigative journalist who has written extensively for many publications. He works for The New Yorker. The book was written in 2021.

This 560-page book — divided into three parts — explores the history of the infamous Sackler family and the role they and the company they founded, Purdue Pharma, played in the opioid epidemic that engulfed the United States. While the Sackler name had been on my radar since 2019, uncharacteristically of me, I did not bother to look them up online. What Patrick did in this book, for which he interviewed over 200 people, reviewed tens of thousands of litigation documents, and read at least four books, is lay bare how the company got started, its influences, and its philanthropic gestures. The philanthropy particularly masked how the actions of 3 generations of the family led to the deaths of over 500,000 people.

As an immigrant Jew from Austria, their patriarch Isaac gave birth to three sons, and was committed to giving them the very best education. Arthur, the first child, would lead the way and, being an entrepreneurial and enterprising young man, did not just become a medical doctor, he, through the many gigs he juggled, made sure his other brothers did not lack in their quests to becoming medical doctors themselves.

#DoYouKnow that in the 1930s, because Jews became overrepresented in medical schools across the country, American schools blacklisted their Jewish citizens. Many Jews who were interested in medicine had to leave their country. Arthur’s brothers went to Scotland. The three brothers eventually became psychiatrists.

#WILT The treatment of mental health in the past was horrific. A lot of outlandish experiments were performed. There was a doctor in New Jersey in the 1900s who had become convinced that the way to cure insanity was to remove a patient’s teeth. When some of his patients did not appear to respond to this course of treatment, he kept going, removing tonsils, colons, gallbladders, appendixes, fallopian tubes, uteruses, ovaries, and cervixes. In the end, he cured no patients with these experiments, but he did kill more than a hundred of them.

Back to Arthur, it was around the time the three siblings became psychiatrists that the book started with its drama. Arthur was an entrepreneurial whiz who had honed his marketing skills on the streets of New York and was now a psychiatrist. He set up a medical advertising company. Then, together, he silently set up a rival company under the care of a friend. He then went ahead to invent the wheel, conducting widely successful advertising campaigns for brands like Pfizer. When Arthur was inducted into the Medical Advertising Hall of Fame, half a century later, the citation would say, “No single individual did more to shape the character of medical advertising than the multi-talented Dr. Arthur Sackler.” It was through Arthur’s advertising efforts that, within eighteen months, Pfizer increased its sales force from eight men to three hundred. Not long after, they would have two thousand.

This avalanche of men and women in full force selling drugs would have unintended consequences. Medicine was now being pitched to doctors on more or less the same terms as swimwear or auto insurance was marketed to average consumers. The seduction was intense, and it started early. Drug companies began offering free stethoscopes to students in medical schools, a tactic he had used on the streets when he, Arthur, distributed free rulers stamped with the names of his business school clients to students during his high school. Another company provided free textbooks. Doctors were sponsored to attend conferences by drug companies. Not content with these overtures, Pfizer sent out drugs with the words of several doctors (and their contacts) who testify to the drugs’ potency. Alas, the doctors were made up.

#NewWordAlert arriviste — an ambitious or ruthlessly self-seeking person.

You had a situation where medical journals were started by those catering to drug companies. Arthur started some of his own. Arthur seems not to have any qualms about his roles as head of both a medical newspaper catering to millions of doctors and a pharmaceutical advertising firm. As early as the late 1960s, the New England Journal of Medicine, where many of Arthur’s ads appeared, was making more than $2 million a year advertising for drug companies with little or no due diligence.

Of course, when the tranquilizer addiction — among them drugs like Librium and Valium that had been aggressively marketed by Arthur — broke out, it was easy to point fingers. Interestingly, the fact that establishment figures such as former first lady Betty Ford admitted to using Valium and Senator Edward Kennedy blamed tranquilizers for creating “a nightmare of dependence and addiction” did not force the pharmaceutical industry to face the music. Employing science, scientists and the medical media takes like “there are some people who just get addicted to things — almost anything” and “addiction to tranquilizers occurs very rarely” were bandied around.

These tactics and more would be used decades after. But before then, Arthur and his brothers got super wealthy. With mortality lurking, the Sackler family invested in immortality. They donated to institutions of art and science. Across three continents, they got their names etched in landmark structures, including university buildings and museums. And because they never took their companies public and barely granted interviews, all the public knew about them was their philanthropy, as seen around the world. They brought life to the saying, “If you put your name on something, it’s not charity, it’s philanthropy. You get something for it. If you want your name on it, it’s a business deal. “

#WILT In April 1967, Egypt gave the ancient temple of Dendur to the United States.

Unfortunately, by the time Arthur died, he had fallen out with his brothers and their mutual businesses were no longer the same. In settling his estate, his brothers bought his share in the company they had founded, taking advantage of the fight over his estate by his wives and children. The lawsuits and countersuits took on a life of their own, so much so that the saga took on the name “Matter of Sackler”. By one estimate, the litigation over the estate cost the Sacklers more than $7 million in legal fees.

That didn’t matter to the other two families because, as the book shows in detail, the legacy of Arthur Sackler would live on in a company created from the original one. Were Arthur alive to see Purdue Pharma’s success, he would have been proud. Taking advantage of the tens of millions of Americans with pains of all kinds, Purdue Pharma’s marketing of its key offering — OxyContin — relied on an empirical circularity: the company convinced doctors of the drug’s safety with literature that had been produced by doctors who were paid, or funded, by the company.

Doctors were subconsciously taken. Purdue advertised OxyContin in medical journals, sponsored websites about chronic pain, and distributed a dizzying variety of OxyContin swag: fishing hats, plush toys, luggage tags. The sales reps left a trail of these giveaways wherever they went, so that anywhere a doctor turned, she would be greeted by reminders of the product.

Doctors were consciously taken. In some years, Purdue allocated as much as $9 million just to buy food for doctors. The funds were not a waste. In a 1996 email, Richard — the son of one of the Sackler brothers but who most embodied the ethos of his uncle Arthur — pointed out that, according to Purdue’s own data, “physicians who attended the dinner programs or the weekend meetings wrote more than double the number of new Rxs for OxyContin compared to the control group.” (“Rx” is an abbreviation for prescription.) He noted that “weekend meetings had the greatest impact.”

Marketing was just the first step. The drug itself is potent to the point of addiction. So real was the addiction level that robberies were happening in hospitals and pharmacies over OxyContin. OxyContin, which is derived from the problematic opium poppy known for its addictive properties, hooked its victims, whether prescribed by doctors or obtained from the now-well-established black market.The insidious problem with OxyContin is that it is the fear of withdrawal that keeps its victims addicted to the drug, not the euphoria of the high. When it hit, they could summon no words to capture the mental and physical agony. Their whole bodies raged with searing, incandescent pain. It felt as if the skin had been peeled right off of them. Innocent people who thought they were adhering to the instructions of the doctor could no longer get themselves off the drugs.

By now, you may be asking about the role of drug regulators in all of this. And that would be a good question. The Food and Drug Administration (FDA) was compromised. Recognizing that the FDA regulator in charge of the approval was about to retire, Purdue Pharma dangle go him an offer of a position in the private sector worth nearly $400,000 per year. In subsequent testimony, he denied making any overtures to Purdue before he ultimately took the job, insisting that he was approached by a headhunter only after he had left the FDA. He argued that the company would want to hire him, not because of any favors he might have done for Purdue, but because he was “a particularly fair and effective FDA reviewer.” This is difficult to believe given that, unlike other filings that linger at the FDA for years, this product was approved in eleven months and fourteen days.

In any case, in the hundreds of litigation that happened after the release of the drug to the market, Purdue Pharma would lean on the approval of the FDA to say that they did nothing wrong because the drug was approved and certified for use by the FDA. Even when the drug’s rejig led to a boom in heroin and fentanyl supply in the United States, the company and the family continued to deny allegations of wrongdoing.

A considerable part of the book was devoted to the suits brought by individuals, states, and eventually the Department of Justice. As they swamped, the efforts of the company and family to hide their misdeeds began to return less and less. Artists, journalists, and state attorneys utilized the courts and media to bring to light how much pain the empire of the Sacklers had caused. More than 165,000 Americans had lost their lives to prescription opioid abuse since 1999. Overdoses had now surpassed car accidents to become the leading cause of preventable death in America. In a mid year update to the Sacklers in June 2016, staffers told the family that, according to surveys, nearly half of all Americans knew someone who had been addicted to prescription opioids.

To the chagrin of the reader, the family was less concerned about the fate of individuals who had died and the families they left behind. They were concerned more about those who were on campaigns about having their names removed from institutions they had devoted their wealth to. The legacy that Arthur had carefully cultivated was torn apart. Medical schools as well as world-class museums and art galleries removed their names.

Despite evidence from economists and health agencies like the CDC, the Sacklers have refused to accept their role in the opioid crisis, which was killing 115 Americans each day. Between 2006 and 2015, they have spent over $700 million on lobbying in Washington and in all fifty states.

That seems to have worked. Unlike other lawsuits where company officials were sentenced to prison over these behaviors, no one in the Sackler family will due to settlement pronouncements. While Purdue Pharma was dissolved on September 1, 2021, and the Sacklers agreed to pay $4.5 billion over nine years, with most of that money funding addiction treatment, the Sacklers had moved a substantial amount of money to offshore accounts to protect it from claims. So in the end, according to the victims, the Sacklers got away.

It is a powerful indictment of American corruption and greed, compromised regulation, and the fruit of a corrupted seed.

This book by Patrick Radden Keefe is a strong contender for the best book I have read this year. It is not just about the story; it is the way he weaved the different aspects and merged them into a succinct narrative. As a writer myself, several times as I read, I asked myself how I could train to write like this. It would have been an injustice if the book had not won awards. And I am glad it did. It was shortlisted for the 2021 Financial Times and McKinsey Business Book of the Year Award and longlisted for the 2022 Andrew Carnegie Medal for Excellence in Nonfiction. It was also selected for The Washington Post’s “10 Best Books of 2021” list.