Thousands of years ago, at the dawn of human history, someone figured out that if you slice into the head of an [opium] poppy, it will ooze a milky paste…

Empire of Pain
  • Copyright: 2021
  • Pages: 441 ex-notes
  • Year(s) Read: 2023

This book is remarkable. (Even the cover is great. Note the OxyContin pills in the pillar.)

I was late to the opioid party. Before reading Empire of Pain, I barely knew anything about the epidemic and could not have cared less about the Sackler family, the manufacturers of OxyContin.

A few chapters in, I was addicted.

This is a book about very* rich and powerful people.

According to deposition testimony by one of Purdue’s own experts, the family had taken as much as $13 billion out of the company.

p. 417

If you look closely, it’s also a book about gaslighting, human nature, and incentives. It’s a book about denial, family, complexity, and the mechanisms of corruption.

If I’ve read 75 “business” books, this is better than all of them and it’s not a business book.

A business book may talk about the importance of culture.

This book shows us that if we make $100 dollars a year, any penalty, fee, death, settlement, bribe, or other cost, that is less than $100 dollars a year, is worth it.

We are shown a dark inverted twist of the cliché: If you can pay the fine, just do the crime.

At a glance, the $4.3 billion figure might seem like a lot of money.

But the fine print of the deal stipulated that the Sacklers would pay it out slowly, over nine years.

Because their remaining fortune, estimated to be roughly $11 billion, continued to generate huge annual income in the form of interest and investment returns, they would likely be able to pay the whole sum without ever touching their principal.

Not long after finalizing this arrangement, Judge Drain announced that he was retiring form the bench.

p. 433

The Sacklers prided themselves on their ability to cultivate political connections.

“We can get virtually every senator and congressman we want to talk to on the phone in the next 72 hours,” Richard boasted in 2001.

p. 249

Empathy, ethics, and responsibility may have a place in Disney movies and The Land of Make Believe. But, not at Purdue Pharma, the Sackler family’s company.

The ancient Romans had a tradition. When one of their engineers constructed an arch, as the capstone was hoisted into place, the engineer assumed accountability for his work with real skin-in-the-game: he stood under the arch.

You won’t see the Sacklers standing under any new arches.

If you want a good system, an individual must be responsible for every action. If you assign responsibility vaguely, you will get a bad system because it allows people to displace blame.

What was their big crime? Arguably the original FDA approval. The company knew its product was addictive and dangerous. The company also knew where every single pill was originally sold.

The package insert for OxyContin said, “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of the drug.”

The question is: “Believed by whom? It seemed more aspirational than scientific.”

We learn that no one wanted to take responsibility for writing that sentence. Words can be important, and the marketing team’s entire campaign rested on this sentence. They were trained to overcome objections about possible addiction by referring to this FDA-approved sentence.

If we could go back to 1995, we should have made the Sacklers take two (2) 80mg OxyContin per day for a couple months and confirm it’s not addictive.

Patrick Keefe shows us who should be standing under arches.

The Sacklers befriended and bribed Curtis Wright, who oversaw pain medication at the FDA and would be the medical reviewer and chief inquisitor in charge of approving OxyContin.

On December 28, 1995, the FDA approved OxyContin.

After the approval, [Wright] resigned from the FDA. Initially, he joined a small pharmaceutical firm in Pennsylvania called Adolor.

Barely a year later, he moved on, to a new position at Purdue Pharma, in Norwalk, with a first-year compensation package of nearly $400,000.

p. 196

It is popular today to hate on rich people. We are hit over the head with Tax the Rich, The One Percent, yadda yadda.

I love making money. I respect people that earn it honestly and with integrity (which is hard to define).

However, regardless of your political views and wealth, this book will stir up any latent resentment you have toward people becoming obscenely wealthy at your expense.

Purdue paid one law firm $50 million.

p. 277

For what, you might ask? Those lawyers crafted their genius deals with prosecutors.

For example, they negotiated settlements with the condition that they admit no wrongdoing and the facts are permanently sealed. More importantly, they get to keep selling OxyContin.

The family’s apathy is epic. Not only did they have zero responsibility for the hundreds of thousands of opioid deaths, those deaths meant lost customers and threats to future profits.

It is difficult to get a man to understand something, when his salary depends on his not understanding it.

― Upton Sinclair

How can we grow sales in spite of all these people dying from our product?

Doctors were offered all-expenses-paid trips to “pain management seminars” in places like Scottsdale, Arizona, and Boca Raton, Florida.

In the initial five years after OxyContin’s release, the company sponsored seven thousand of these seminars.

p. 200

The Sacklers were masters of gaslighting.

Sure, people can be more prone to addiction than others, but the genius of the Sacklers was convincing people that it was the people’s fault, not theirs. They were the victims!

Their drug wasn’t the problem, it was really a law enforcement problem.

Those are the attention-grabbers.

a close up shot of a poppy flower
Opium poppy

The book has only a few weaknesses:

  • Minimal attention is given to fentanyl
  • When taken properly and temporarily, addiction and abuse of painkillers appears to be rare
  • The author waits until the end of the book to say the quote below. Although he says, “As I make clear throughout the book,” he didn’t really make it clear throughout the book. Keefe is such a talented writer, he made me hate a family I knew nothing about and have no connection to, so this makes us ask, “Yes, but is there more to the story? Do they deserve all the blame?”

As I make clear throughout the book, OxyContin was hardly the only opioid to be fraudulently marketed or widely abused, and my choice to focus on Purdue is in no way a suggestion that other pharmaceutical companies do not deserve a great deal of blame for the crisis.

The same could be said for the FDA, the doctors who wrote prescriptions, the wholesalers that distributed the opioids, and the pharmacies that filled the prescriptions.

p. 438

As you can probably tell, this book got me hyped up. I know several nurses, so I asked some of them their thoughts on opioids. Their responses (posted at the end) are extremely interesting.

Most of the information above comes later in the book.

It is organized into three parts, which are appropriately called books, because they are so different.

  • Book 1: Biography of Arthur Sackler
  • Book 2: Dynasty
  • Book 3: Legacy

How It Started

What is wild is that this story really starts in the 1950s, with Arthur Sackler, the patriarch of the family.

As a single guy, this makes me think I really need to get going if I’m going to start a dynasty.

He is arguably the person most responsible for OxyContin and he died in 1987, 8 years before its release.

Basically, Arthur gets rich from aggressively marketing addictive drugs. When he dies, the family says, “Hold my beer and watch this,” and uses that strategy to get OxyContin into as many people’s bodies as possible.

I knew where the book was heading, but I couldn’t help getting drawn in and liking Arthur at first.

He squeezed 3 or 4 lifetimes into one, which is what I’m trying to do.

Like Thomas Jefferson, Artie had eclectic interests art, science, literature, history sports, business; he wanted to do everything.

p. 13

He was born in 1913, became a psychiatrist and in 1942, he also started working for a marketing agency called McAdams.

His big idea was…

Seeing that physicians were most heavily influenced by their own peers, he enlisted prominent doctors to endorse his products.

p. 36

He became president of the marketing company two years after joining, and later bought it.

Meanwhile, Pfizer developed penicillin in the 1940s. It was revolutionary, but it wasn’t patented, which meant it was cheap.

Pfizer wanted something that it could patent and sell at a higher price.

This was the era of the “miracle drug.” They developed a “broad-spectrum” antibiotic called Terramycin. “Broad-spectrum” is a term made up by advertisers.

Pfizer was Arthur’s big client and he helped them market this new drug.

The notable feature about the drug wasn’t the drug. It was the marketing of the drug.

Within 8 years, Pfizer’s salesforce increased from 8 people to 2,000 people.

Pfizer’s competitor Roche hires Arthur too, and as you’ll see in the timeline below, things take off.

Arthur started out super frugal, but then the marketing money starts burning a hole in his pocket.

The book takes a bizarre detour into Arthur’s addiction to, of all things, Chinese art. Eventually, his collection gets to $100 million or something crazy.

This has deeper meanings than you think though, because the real goal is immortality (and tax avoidance). He and the family start putting their name on every museum and Ivy League school that they can. Given what we know now, there is a deep irony to this attempt.

He also used his money to buy another business.

In 1952, Arthur bought a company for his brothers.

Officially, it would be a partnership; each brother would own a third. But the money was Arthur’s, and he would effectively be a silent partner: Mortimer and Raymond would run the business, with Arthur behind the scenes.

They bought the company for $50,000. It wasn’t much: a patent medicine business with a few run-of-the-mill products, $20,000 in annual billing, and a narrow redbrick building on Christopher Street in Greenwich Village.

But it had a sturdy, blue-blooded name, which the brothers decided to keep: Purdue Frederick.

p. 52

Timeline & Key Events

  • 1913: Arthur Sackler is born. The same year, aspirin-maker Bayer stops making heroin.
  • 1916: Mortimer Sackler is born.
  • 1920: Raymond Sackler is born.
  • 1952: Arthur buys Purdue Frederick.
  • 1960s: Roche hires Arthur to market Librium and Valium. Negotiates commission based on volume.
  • Librium is the most prescribed drug in America, until it is overtaken by Valium in 1968.
  • 1966: The Sacklers buy Napp Laboratories, a company in England.
  • In the 1970s, Napp produces a new product: a morphine pill.
  • 1971: Richard Sackler (Raymond’s son) joins Purdue Frederick, who eventually becomes the company president.
  • Napp develops a special coating system that allowed the diffusion of a drug into the bloodstream of a patient to be carefully regulated over time.
  • 1980: Napp applies this to morphine, names it MS Contin, and begins selling in the United Kingdom. It takes off.
  • 1984: Purdue starts selling MS Contin in the US.
  • 1987: Arthur Sackler dies.
  • 1990: The Company wonders if it would be possible to use the Contin time-release system as a delivery mechanism for other opioids, in order to secure new patents.
  • 1995: OxyContin gets FDA approval
  • 2007: Purdue Frederick pays $600 million in fines and settlements over OxyContin.
  • 2007: Family uses Purdue Pharma entity going forward. Expands OxyContin salesforce by hiring 100 more reps.
  • 2014: The Sacklers knew the company was being investigated and began transferring money offshore, beyond the reach of U.S. authorities.
  • 2021: Judge Drain signs off on the final deal in the bankruptcy.
  • In negotiations with Massachusetts, and other state, the Sacklers had increased their pledge to $4.3 billion.
  • The family was issued a sweeping grant of immunity from any future civil claims related to the opioid crisis.

The opioid epidemic feels like the financial crisis of 2009. Everyone involved is a little guilty, because everyone benefits in the short term.

Everyone in the supply chain makes money. The consumer in the financial crisis gets a house for a while. The consumer in the opioid crisis feels no pain.

These are understandable desires, but there is a lot of hope involved.

Everyone hopes it works out, and hope is the most dangerous emotion.

Several people read drafts and excerpts of this before posting and it has led to some of the most interesting conversations I have had this year.

The Sackler family did not cooperate with my efforts to research this book.

Patrick Keefe, Empire of Pain (p. 446)

See also:

Nurse Thoughts on Opioids

A lot of times in healthcare we are put in a sticky situation when it comes to opioids.

Providers/nurses were taught that pain is the fifth vital sign (along with heart rate, blood pressure, temperature, respiratory rate) so that we make sure we take people in pain seriously.

A lot of people in the ER do actually need stronger pain medication so we’re giving them Oxy, morphine, sometimes fentanyl.

On the other hand, we do have a big population of people with chronic pain disorders and people who are drug seeking who take advantage of coming to the hospital and getting the doctors to give them whatever they want.

It’s a sticky situation because, again, we were taught to take their pain seriously…but, obviously you don’t want to over-medicate or cater to someone who is abusing the system.

These patients are the ones that one dose of morphine isn’t going to touch their pain so we’re giving way more to them than the average patient. And even when the doctors don’t give in and give them what they want… these patients tend to make a scene and bother the nurses and the doctors into giving them what they want.

Then, not to mention patient satisfaction scores… we want to keep patients happy so try to stay on their good side. Some doctors are good about not caving in, but the patients know what they can get away with.

It’s definitely not black and white. It’s easy for an outsider who isn’t in healthcare to think it’s as easy as just not giving these meds. But these patients (especially the chronically ill) have a higher tolerance so need more medication to get relief… so even though as providers we may be uncomfortable to give so many meds/ higher doses especially if we think they are drug seeking… we still have to treat them as humans and take care of them.

It’s messy.

On responsibility: It would be easy to blame the prescriber or big pharma or even the patients who are abusing.

I think it’s more of a system issue.

Obviously, some people really do need pain medication for various reasons.

But, maybe if we were all focused more on preventative measures and to avoid getting to that point in the first place, the world would be a better place. Our healthcare system is very much reactive rather than proactive if that makes sense. If we could just turn it all around and focus on being healthy and alternative treatments/interventions and just taking care of ourselves.

Easier said than done, of course.

Pharmaceutical Notes

Pharmaceutical patents last 20 years. Once you lose the patent, profits fall off a cliff.

If Purdue was going to lose the monopoly on its flagship painkiller, perhaps it would be possible to use the Contin time-release system as a delivery mechanism for other opioids, in order to secure new patents.

So, basically Oxycontin is time-released oxycodone.

Oxycodone is roughly twice as potent as morphine.

Thanks to James Bunch for reading drafts of this.