Empire of Pain: The Secret History of the Sackler Dynasty review

Empire of Pain: The Secret History of the Sackler DynastyEmpire of Pain: The Secret History of the Sackler Dynasty by Patrick Radden Keefe

My rating: 5 of 5 stars

I read this book because it was recommended to me (thanks Jessica!) but also because I wanted to know more about the opioid crisis and how much of it was the fault of the companies involved versus other things.

And this book is pretty convincing that a lot of it was the fault of the Sackler family and their company Purdue Pharma. But it’s also, like, boy does capitalism not work sometimes. The more drugs Purdue sold, the more money they’d get, so it’s not a big surprise they hired a ton of sales reps, gave away vacations to people who sold the most, and stretched the truth about their product.

The FDA is supposed to prevent some of this, but this sounds a classic case of regulatory capture – see notes about Curtis Wright below.

Anyway, I don’t say this to diminish the culpability of the Sackler family because they definitely did a lot of bad stuff. (see below!) But it’s also a pretty messed up system!

The book starts back in time a bit, which I wasn’t excited about because I wanted to get to the interesting part, but it turns out the behavior of Arthur Sackler in the 1950’s and 60’s was just a predecessor of what Purdue Pharma did with OxyContin.

As to why Purdue and the Sacklers pushed OxyContin so hard and helped cause the opioid epidemic, it really seems like the answer was simple and straightforward: money.

Another thread of the book is Arthur Sackler’s philanthropy. He was a big believer in “all you have is your name” and so gave a lot a way to the Metropolitan Museum of Art, the Smithsonian, etc. (here’s a partial list) And it sounds like he treated philanthropy as any other sort of business, and wanted to get the Sackler name on as many things as possible. Maybe if you live in New York/Paris/London or are more tuned into fine art you’ve heard of the Sackler name? (I hadn’t before opioids) But he and the rest of the family were extremely secretive about their business – it wasn’t until the late 2010s that people started refusing the family’s donations because of their ties to the opioid crisis.

The book ends on a mixed note – the Sackler name is basically in ruins, and Purdue Pharma is in bankruptcy. But the Sacklers get to keep the vast majority of their billions of dollars. A lot of this is because they took billions out of Purdue Pharma to give to themselves, which is legal because it was a privately owned business, but is also extremely convenient because it’s much harder for lawsuits to get at it.

The book is long but more interesting than I expected, just like Say Nothing was. I recommend it!

Odds and ends:
– Arthur Sackler was the prime mover that got the family into the pharmaceutical business. He was a doctor but wore a lot of different hats. One of his more lucrative hats was in pharmaceutical advertising, where he pioneered advertising about drugs directly to doctors. (in fact, the term “broad spectrum antibiotics” was invented for his ad campaign for Terramycin!) This was wildly successful, and he justified it by saying that he was just “educating” doctors and it was laughable that doctors would be influenced by advertising campaigns to prescribe things they shouldn’t. Later studies showed that doctors are susceptible to advertising just like the rest of humanity – one in 2016 showed a single meal of $20 for a physician can be enough to change the way that they prescribe!
– Arthur also introduced an early form of “native advertising” (an ad that kind looks like a news story) by paying to include a sixteen-page supplement in the New York Times. Sigh.
– Arthur, like the rest of the Sackler family to come, was extremely secretive about his business. At the time there were two major advertising companies that catered to pharmaceutical companies – one that Arthur ran, and a competing one run by a man named Bill Frolich. But Arthur secretly held a stake in Frolich’s company as well! He also secretly ran a weekly newspaper geared to doctors named the “Medical Tribune”, which ran articles favorable to Arthur’s clients. (as well as lots of ads!) This newspaper reached millions of doctors around the world.
– In 1960, the FDA prohibited advertising from pharmaceutical companies to consumers. Arthur got around this by getting Life magazine to run a story about a lynx at the San Diego Zoo that had been given Librium (a mild tranquilizer) and made it gentle and friendly. The article mentioned in passing that Librium “may have important human uses”, and ran a month before Librium went on the market for people.
– The book mentions Arthur would put a lot of ads in the New England Journal Medicine, and I don’t read it but it still takes ads today, and that seems kinda weird to me!
– Arthur’s agency made an ad for Pfizer about the benefits of Sigmamycin (another antibiotic), saying it was clinically proven and including the business cards of eight doctors that appeared to be endorsing the product. Turns out none of the doctors existed!
– The Sacklers unsurprisingly hated generic drugs, and they put a story in the Medical Tribune about a VA hospital that switched from Thorazine (a drug for people with schizophrenia) to a generic version and “all hell broke loose” as patients ran amok and only got better when the doctors switched back to the non-generic version. The FDA investigated and concluded this never happened.
– Around 1900 Bayer marketed heroin for medicinal purposes, and claimed that it wasn’t addictive like morphine was. Of course, they were totally wrong; heroin is six times stronger than morphine and just as addictive, and after 10 years or so(!) Bayer stopped making it. In the 1990s, Purdue Pharma was preparing to launch OxyContin, and their marketing team noticed that doctors had the impression that oxycodone (the drug OxyContin is based on) was weaker than morphine. In fact, oxycodone is twice as strong as morphine, but Purdue decided to exploit this misunderstanding to convince doctors to prescribe it more often than they would otherwise, because doctors were (rightfully!) wary of prescribing morphine unless it was absolutely needed.
– FDA approval is a big part of getting a drug approved, and the FDA determines what it can be used for, what has to go on the label, etc. Curtis Wright was the official at the FDA in charge of approving OxyContin, and at one point a team from Purdue rented a room near Wright’s office and spent several days working with him to look at the available studies about OxyContin. And wouldn’t you know it, the drug was approved in under a year (which is very very quick for this sort of thing), and the wording on the label included some text about how delayed absorption “is believed” to reduce the abuse liability of the drug. Shortly after the approval Wright left the FDA for private industry, and a year later he joined…Purdue Pharma, with a very generous starting salary. This is the definition of regulatory capture!
– According to Purdue’s own data, physicians who attended programs/meetings run by Purdue wrote double the number of new prescriptions for OxyContin!
– Purdue’s general defense against people that blamed them for the opioid epidemic was that less than 1 percent of people would become addicted, and those that did were junkies that were already prone to addictions; it certainly wasn’t Purdue’s fault! And the package label claimed that at under 60 mg, people could stop “abruptly without incident”. But Purdue’s own internal studies showed that two out of seven subjects reported withdrawal symptoms even on low doses. Purdue really had no evidence that OxyContin was less prone to abuse than other painkillers, but they loudly repeated this claim to their sales reps, who told doctors this.
– Purdue also funded astroturf groups like the American Pain Foundation and the American Academy of Pain Medicine. And honestly this is a bit tricky because chronic pain is something that seems to have been undertreated in the past. But of course these groups were just shills for Purdue, and Purdue portrayed any attempt to curtail OxyContin use or distribution as an attack on chronic pain sufferers.
– Purdue also spent a lot of money on lobbyists to get influence in government. When prosecutors in Virginia were preparing to bring a case against Purdue, Purdue officials appealed to James Comey, who was the deputy attorney general at the time, to get him to kill the case. Comey did meet with the prosecutors, but told them to continue, which makes sense given what we know of him now…
– There are a lot of stories of phony clinics set up that were very easy for Purdue to spot. (in one case a single doctor prescribed eleven thousand pills in a month!) And in fact Purdue did keep a secret list of potentially problematic prescribers, known as “Region Zero”, but didn’t report them to the authorities until after the clinic had already been shut down. One Purdue employee, Jack Crowley, said in the five years he spent investigating suspicious pharmacies the company didn’t stop sending pills to a single one.
– In 2010 Purdue released a reformulated version of OxyContin (called OxyContin OP) that was supposed to be uncrushable so people couldn’t take all the oxycodone at once. (it sounds like it actually worked pretty well) But the patent for the original OxyContin was set to expire in 2013, and they asked the FDA to refuse to allow generics of the original OxyContin because it was unsafe! (which the FDA did!) So it seems like this was more likely a ploy to extend patent protection than any sort of good behavior.
– The Sacklers got so used to the profit margins with opioids that they didn’t want to try to develop many other drugs, because they weren’t as profitable.
– The DEA has a limit on how much oxycodone you can legally manufacture, but Purdue’s lobbyists went to work, and the DEA raised the limit thirty-six times between 1994 and 2015!
– There are just some jaw-dropping numbers about the scope of the epidemic – by 2016, 2.3 million people in Ohio (around 20% of the state) had a prescription for opioids! United Health (an insurance company) found that “hundreds of thousands” of their policyholders had a prescription for OxyContin and later became addicted.

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3 thoughts on “Empire of Pain: The Secret History of the Sackler Dynasty review”

  1. It is unwise to assume the Sacklers did anything wrong, in fact they and their scientists and analytical chemists did much good.

    It was properly revealed that MUCH severe pain was being under-treated and the era of “Pain as the Fifth Vital Sign” emerged in the 90’s, this was not a marketing ploy but did much good.

    Oxycontin is not just another opiate but proved to be a formulation that IS more effective in a smaller dose, with less side-effect than many before it and since.

    Abuser make their own bed and like we would not blame BIG SODA for making Diabetics we do not make pharmaceutical manufacturing suffer for true abusers. Now “TRUE ADDICTION” is very rare (4 in 1000) and a VERY serious condition, it is nothing like someone who simply wants to abuse and then keeps using because they find that withdrawing sucks.

    There are many medications that produce a ghastly withdrawal, some worse than Opiates. For example; any anti-depressant, the ‘biologics’ (gabapentin, cymbalta, humira, etc). FURTHER SOME MORE is it doesn’t matter how good an Opiate can make you ‘feel’, only an idiot would go all in for that feeling some of the time and spend the majority of the other part of the time seeking and withdrawing. Withdrawals are JUST AS BAD AS THEY LOOK.


    1. Curious if you’ve read the book. I agree that chronic pain was under treated, and surely Oxycontin was a net positive for some people. But it’s clear Purdue knew what they were doing, that way more people were getting addicted than people knew, and just didn’t tell anyone.

      (a lot of your last few paragraphs sound a lot like Purdue’s defenses!)


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