Empire of Pain: The Secret History of the Sackler Dynasty

by Patrick Radden Keefe

According to the Centers for Disease Control and Prevention, in the quarter century following the introduction of OxyContin, some 450,000 Americans had died of opioid-related overdoses. Such overdoses were now the leading cause of accidental death in America, accounting for more deaths than car accidents—more deaths, even, than that most quintessentially American of metrics, gunshot wounds. In fact, more Americans had lost their lives from opioid overdoses than had died in all of the wars the country had fought since World War II.

After completing their undergraduate degrees at NYU, both Mortimer and Raymond had applied to med school. But during the 1930s, many American medical programs had established quotas on the number of Jewish students who could be enrolled.

Now he recruited Mortimer and Raymond to join him at Creedmoor, and soon they too were administering shock therapy. Among them, the brothers conducted the procedure thousands of times, an experience they came to find demoralizing.

With his unusual experience as an editor, a marketing director, and an adman, Arthur knew how to attract breathless press coverage. “The doctors think they have found a means of treating mental ailments without hospitalization,” The Philadelphia Inquirer announced.

Seeing that physicians were most heavily influenced by their own peers, he enlisted prominent doctors to endorse his products. It was the equivalent, for physicians, of putting Mickey Mantle on a box of Wheaties.

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 Arthur, the citation continued, who brought “the full power of advertising and promotion to pharmaceutical marketing.”

Rather than cutting back on his professional commitments in order to accommodate his new family, Arthur now took on more projects than ever. He became editor of the Journal of Clinical and Experimental Psychobiology. He started a medical publishing company. He launched a news service for physicians, became the president of the Medical Radio and Television Institute, and started a round-the-clock radio service, which was sponsored by pharmaceutical companies. He opened a laboratory for therapeutic research at the Brooklyn College of Pharmacy, on Long Island.

“If you asked me to define the term ‘genius,’ I would attribute it to him,” Keusch continued. “I would see him in meetings with the clients. Upjohn. Roche. He would take over. It all boiled down, ultimately, to him. You’d have all these people around the table, all these titles. But he was the one who made the most sense. I thought he was the most brilliant person I’d ever met. In essence, he created the business.”

one of the entities in which Arthur possessed a clandestine stake was his ostensible rival, the L. W. Frohlich agency. To the outside world, Sackler and Frohlich were competitors. But the truth was, Arthur had helped Frohlich set up his business, staking him money, sending him clients, and, ultimately, colluding with him in secret to divvy up the pharmaceutical business.

You might think that the journals would have an interest in vetting the advertisements that people like Arthur Sackler and Bill Frohlich placed, but many of these publications were heavily dependent on advertising revenue. (The New England Journal of Medicine, where many of Arthur’s ads appeared, was making more than $2 million a year in this manner by the end of the 1960s, most of it from drug companies.)

In 1964, some twenty-two million prescriptions were written for Valium. By 1975, that figure reached sixty million. Valium was the first $100 million drug in history, and Roche became not just the leading drug company in the world but one of the most profitable companies of any kind. Money was pouring in, and when it did, the company turned around and reinvested that money in the promotion campaign devised by Arthur Sackler.

By the time Roche allowed its tranquilizers to be controlled, Valium had become part of the lives of some twenty million Americans, the most widely consumed—and most widely abused—prescription drug in the world.

“The Sackler empire is a completely integrated operation,” Blair wrote. They could develop a drug, have it clinically tested, secure favorable reports from the doctors and hospitals with which they had connections, devise an advertising campaign in their agency, publish the clinical articles and the advertisements in their own medical journals, and use their public relations muscle to place articles in newspapers and magazines.

Arthur had never had much faith in government regulators and tended to regard them, contemptuously, as bumbling bureaucrats, the kinds of people who probably went into public service because they couldn’t get into med school.

Think of it as the dangle: a wealthy patron can often enjoy favor and influence with a hard-up institution that are far out of proportion to any gifts that have actually been made, because the canny donor learns to dangle the possibility of future gifts, and that is a possibility that the museum or university cannot afford to overlook. When the dangle is executed correctly, there is almost nothing that the institution will not do to keep the donor (or even the prospective donor) happy.

His days were spent at the Hôtel du Cap-Eden-Roc, a storied resort on a promontory overlooking the Mediterranean in Cap d’Antibes, where F. Scott and Zelda Fitzgerald used to drink and the Kennedys had once vacationed.

Wow. I love this place. This tarnishes it a bit. Ok maybe not.

“Mortimer was a better philanderer than he was, with topless young ladies in Cap d’Antibes.” According to Rich, Arthur would occasionally refer, with “no small amount of envy,” to his brother’s exploits in the South of France.

According to a subsequent investigation by The New York Times, the FDA examined this incident and found the story in the Medical Tribune to be completely bogus. The hospital had actually started administering the generic medication, without incident, “six months before the purported problems began.”

Because morphine had long been perceived as a drug with a high risk of addiction, physicians reserved it for particularly severe cases. Consequently, patients and their families were often reluctant to have doctors prescribe morphine, because in the popular imagination it was seen, as Richard put it, to be “a death sentence.”

Arthur Sackler had realized that a canny pharmaceutical executive could enlist ostensibly independent medical practitioners to validate his product, and this event was precisely the sort of carefully orchestrated exercise in validation that he had envisioned.

Oxycodone is roughly twice as potent as morphine, and as a consequence OxyContin would be a much stronger drug than MS Contin.

“once a company gets approval for a drug, a doctor can prescribe it for anything they want.”

The company established a speakers bureau, through which it paid several thousand doctors to attend medical conferences and deliver presentations about the merits of strong opioids. 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.

A 2016 study found that purchasing even a single meal with a value of $20 for a physician can be enough to change the way that he prescribes.

Most pharma companies capped what kind of additional bonus you could make as a rep. Purdue didn’t.” It was, in essence, the deal that Arthur Sackler had worked out for himself when he was marketing Valium. If sales grew, you’d get a bigger bonus. There was no cap. “Purdue never capped,” the executive said, “because they wanted their people to be incentivized.”

subordinates to finish the video in time for the national

OxyContin was priced in such a way that greater dose strength meant greater profits for Purdue. As a consequence, perhaps, another fixation for Richard was the idea of a ceiling effect.

In theory, the Contin coating on each pill was supposed to prevent users from experiencing the full force of the drug’s narcotic payload right away. But people had figured out that if you crushed the pills—even if you just chewed them with your teeth—you could override the controlled-release mechanism and unleash a mammoth hit of pure oxycodone.

But pseudo-addiction generally stops once the pain is relieved, the pamphlet continued, “often through an increase in opioid dose.” If you’re experiencing withdrawal between doses, the company suggested, the answer is to increase the dose.

Shortly after Rudolph Giuliani stepped down from his position as mayor of New York City, he went into business as a consultant, and one of his first clients was Purdue. When he entered the private sector, Giuliani was looking to make a lot of money quickly. In 2001, he had a net worth of $1 million; five years later, he would report $17 million in income and some $50 million in assets. For Purdue, which was working hard to frame OxyContin abuse as a law enforcement problem, rather than an issue that might implicate the drug itself or the way it was marketed, the former prosecutor who had led New York City after the 9/11 attacks would make an ideal fixer. In Michael Friedman’s view, Giuliani was “uniquely qualified” to help the company.

Disgusting

This was a tactic that had been pioneered by the fossil fuel industry, to very successful effect—funding groups that appeared to be grassroots organizations but that actually were awash in corporate money; “astroturf” groups, as they are sometimes called. These organizations produced studies and lobbied agencies and lawmakers.

even established journalists occasionally get “sloppy.” When Dezenhall and his associates began to investigate, they found cracks in Bloodsworth’s reporting. Two of the people she wrote about and described as having “accidentally” become addicted turned out to have abused drugs in the past. A close study of Bloodsworth’s data on overdose deaths demonstrated that while OxyContin might have been in the systems of many of those who died, there were often other drugs present as well. So why single out OxyContin? Udell discussed bringing a libel action against the Sentinel, suggesting that he had a “virtually ironclad case for actual malice.” Instead, Purdue pushed for, and ultimately received, a major retraction from the paper.

It wasn’t as though there were some big enterprise team at the Times working the OxyContin beat. Meier was the team. If they could just knock him out, it would give the company a much freer hand.

Centralized risk

Not long after he received Okrent’s questions, Meier was summoned into the office of Al Siegal, one of the top editors at the Times, to discuss whether it was appropriate for him to write an article about painkillers when he had a book to sell on the same subject. Of course it was appropriate, Meier exclaimed. He was an expert on the subject! He knew the story inside out! He had the technical knowledge! He had the sources! And it’s not as though he had gratuitously mentioned his book in the Rush Limbaugh piece. He hadn’t even mentioned Purdue until the eleventh paragraph. “It was hugely frustrating,” Meier recalled years later. “I felt it was unfair.”

when the government fines corporations, rather than sending executives to jail, it amounts to “expensive licenses for criminal misconduct.” And this appears to be the way that the sanction against Purdue was perceived by the Sacklers and their executives.

a dynamic took hold in which members of the A side were always pressing for greater distributions, because they had more mouths to feed.

But after Purdue released the reformulated version of OxyContin in 2010, as the patent on the original formulation was set to expire, the company made an audacious about-face. Purdue filed papers with the FDA, asking the agency to refuse to accept generic versions of the original formulation of OxyContin—the version the company had been selling all these years—on grounds that it was unsafe. The company said that it was voluntarily withdrawing the original formulation from the market for reasons “of safety.” On the very day that the patent for the original formulation was set to expire, the FDA, ever obliging, declared that the benefits of the old version of OxyContin “no longer outweigh” the risks.

According to a research abstract by a team of scientists at Purdue, after the reformulation, sales of 80-milligram OxyContin pills dropped 25 percent nationwide. On the one hand, this was an impressive metric of Purdue’s success in curbing abuse of OxyContin by developing the new crushproof pills, and the company would tout the investment it made in the reformulation as evidence of its efforts to address the opioid crisis. On the other hand, that drop in sales offered a stark indication that for years Purdue had been deriving a quarter of its revenue on the highest dose of OxyContin from the black market.

Michael’s sister Marissa founded what she described as a “non-profit incubator,” called Beespace, which supported the Malala Fund and other causes.

In 2013, the Serpentine Gallery was renamed the Serpentine Sackler, with a gala opening co-hosted by Vanity Fair and the New York mayor, Mike Bloomberg (who was a friend of the family).

At a publicly traded company, there might have been a genuine reckoning after the 2007 guilty plea, with a bunch of people fired and a real commitment to systemic reform. But at Purdue, even David Haddox, who coined the term “pseudo-addiction,” still held a senior position. “To this day I’m just dumbfounded that passed the sniff test for all those years,” another new-guard employee said of the concept of pseudo-addiction. “The solution is just ‘Give them more opioids!’ I don’t think you need a PhD in pharmacology to know that’s wrong.”

According to a study by the Associated Press and the Center for Public Integrity, Purdue and other drug companies that manufacture opioid painkillers spent over $700 million between 2006 and 2015 on lobbying in Washington and in all fifty states. The combined spending of these groups amounted to roughly eight times what the gun lobby spent.

Arthur might have died before OxyContin was introduced, she said, but “he was the architect of the advertising model used so effectively to push the drug.” And he made his money on tranquilizers! It was a bit rich, she thought, for the Valium Sacklers to be getting morally huffy about their OxyContin cousins. “The brothers made billions on the bodies of hundreds of thousands,” Goldin said. “The whole Sackler clan is evil.”

Though it is only about the size of West Virginia, Tasmania grows 85 percent of all the thebaine in the world.

The only way that the Sacklers could arrive at their 4 percent market share figure was by including, in the category of opioid prescriptions, even short-term prescriptions for low-dosage medicines like Tylenol-Codeine.

“OxyContin was introduced in a market dominated by generic opioids,” a Purdue spokesman told The New Yorker in 2017. The vast majority of prescriptions for opioid pain medications is for generics, he said. But to some who worked at Purdue and were familiar with the convoluted holdings of the Sackler clan, this talking point seemed egregiously insincere, because the Sacklers secretly owned another pharmaceutical company, in addition to Purdue, and it was one of the biggest manufacturers of generic opioids in the United States.

Ohio was an apt forum for this showdown. By 2016, 2.3 million people in the state—approximately 20 percent of the total population—received a prescription for opioids. Half of the children who were in foster care across the state had opioid-addicted parents. People were dying from overdoses at such a rate that local coroners had run out of room in which to store all the bodies and were forced to seek makeshift alternatives. None of the states had enough money or resources to contend with the problem.

From 1997 through the guilty plea in 2007, Purdue had distributed only $126 million in cash to the Sacklers. Beginning in 2008, it started to distribute billions. In a 2014 email to Mortimer, Jonathan acknowledged, “We’ve taken a fantastic amount of money out of the business.” If the Sacklers took money from Purdue and moved it out of the country because they knew that eventually a lawsuit might “get through to the family,” then that might be a form of fraud, James contended, and now she wanted to try to claw back some of those funds.

There was a dark absurdity in the spectacle of Judge Drain and all of these bankruptcy lawyers arguing self-seriously about how to divvy up what was left of Purdue Pharma—which now amounted to cash and assets of roughly $1 billion—when the Sacklers were looking on from the sidelines, apparently untouchable, and holding on to so much more. According to deposition testimony by one of Purdue’s own experts, the family had taken as much as $13 billion out of the company.

Maloney asked Kathe if she would apologize, not in some generic “I’m sorry you’re upset” sort of way, but genuinely apologize, “for the role you played in the opioid crisis.” “I have struggled with that question,” Kathe began. “I have tried to figure out: is there anything that I could have done differently, knowing what I knew then, not what I know now?” But on reflection, she concluded, “I can’t. There is nothing that I can find that I would have done differently.”