Empire of Pain: The Secret History of the Sackler Dynasty

by Patrick Radden Keefe

Bayer proceeded to sell the drug in little boxes with a lion printed on the label, and suggested that differences in the molecular structure of heroin meant that it did not possess the dangerous addictive qualities of morphine. It was an appealing proposition:

People who took heroin often developed a craving for it, and because the body develops a tolerance for the drug, over time, the user tended to require ever stronger doses in order to feel a sense of equilibrium. This is true of all the opioids.

The risks may be formidable, but the high is sublime. Opioids can deliver you, if only for a few minutes, from physical or emotional pain, from discomfort, from anxiety, from need. It is like no other human experience.

Purdue would fight the ticking clock on the MS Contin patent with a radical strategy: the company would unveil this new, more powerful painkiller, OxyContin, and market it against MS Contin—against its own drug—in order to completely upend the current paradigm in pain treatment.

In their market research, the team at Purdue had realized that many physicians regarded oxycodone as “weaker than morphine,” Friedman said. Oxycodone was less well known, and less well understood, and it had a personality that seemed less threatening and more approachable.

A century earlier, Bayer had marketed heroin as morphine without the unpleasant side effects, even though heroin was actually more powerful than morphine and every bit as addictive. Now, in internal discussions at Purdue headquarters in Norwalk, Richard and his colleagues entertained the notion of a similar marketing strategy. In truth, oxycodone wasn’t weaker than morphine, either. In fact it was roughly twice as potent. The marketing specialists at Purdue didn’t know why, exactly, doctors had this misapprehension about its being weaker, but it might have been because for most physicians their chief exposure to oxycodone involved the drugs Percocet and Percodan, in which a small dose of oxycodone was combined with acetaminophen or aspirin.

If the true personality of oxycodone was misunderstood by America’s doctors, the company would not correct that misunderstanding. Instead, they would exploit it.

By the company’s estimates, fifty million Americans suffered from some form of chronic pain. That was the market they wanted to reach. OxyContin would be a drug for everyone.

by the late 1980s medical opinion was beginning to swing. In the first four years of the 1990s, morphine consumption in the United States rose by 75 percent.

Purdue argued that the patented Contin coating on a dose of OxyContin would obviate the risk of addiction. The whole principle of addiction to opioids was premised on the idea of peaks and troughs—of dose and withdrawal, euphoric high followed by the onset of craving. But because the controlled-release coating caused the drug to filter slowly into the bloodstream, over the course of twelve hours, the patient would not experience the immediate rush of an instant-release drug and, as a result, would not be whipsawed between high and withdrawal.

As for Curtis Wright, he had been giving some thought, lately, to leaving the federal government. After the approval for OxyContin went through, he resigned from the FDA. Initially, he joined a small pharmaceutical firm in Pennsylvania called Adolor. But he did not stay long. 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.

As one chemist would subsequently observe, the contents of the steel drum had the makings of a hydrogen bomb.

A federal investigation would eventually cite Napp for a bevy of safety violations and issue a conspicuously modest fine of $127,000. Prosecutors considered bringing manslaughter charges but opted not to in the end. One longtime Purdue Frederick employee, Winthrop Lange, said at the time that Napp should not have made the transition to manufacturing chemicals for other companies on a contract basis, because it didn’t have “the facilities or the technical people to do custom blending.”

A spokesman quoted the company’s owners as saying, “We will not go where we are not wanted.” The spokesman was at pains not to mention any names, but the owners he was referring to were the Sacklers.

the Sacklers assiduously distanced themselves not just from any sense of responsibility for the tragedy but from any connection to it whatsoever.

A generation earlier, when Arthur Sackler helped Pfizer turn Librium into a blockbuster, the company had made it happen by recruiting an army of aggressive salespeople. Now Purdue would do the same for OxyContin,

This was Richard Sackler’s moment, the culmination of his grandest designs. He had sought to remake the family company in his own image, to transform it from a reliably profitable purveyor of unglamorous staples into something more aggressive, more imaginative, more competitive, and less orthodox.

OxyContin should be the first line of defense. And it was good for acute, short-term pain, as well as for chronic, long-term pain; this was a drug you could use for months, years, a lifetime, a drug “to stay with.” From a sales perspective, it was an enticing formula: start early, and never stop.

What causes addiction, they explained, is the “peak and trough” phenomenon. Because OxyContin released its narcotic payload into the bloodstream gradually, the peaks and valleys were less pronounced, which made addiction less likely.

The marketing of 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.

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.

Back in the 1950s, Arthur Sackler and his friend Bill Frohlich had founded the market research firm IMS—the

IMS stayed in business and grew, over the decades, into a big data company with extraordinarily fine-grained information about the prescribing habits of physicians. Using data supplied by IMS, Steven May and other sales reps could look into which doctors to call on. They targeted certain regions in particular—places where there were a lot of family physicians, where people had workers’ comp, injuries they had sustained on the job, disabilities.

Purdue also explicitly instructed sales reps to target family physicians who were likely to be naive about opioids—doctors who had little experience prescribing this kind of medication.

In the first year, Purdue sold $44 million of OxyContin. The following year, sales more than doubled. The year after that, they doubled again.

OxyContin was priced in such a way that greater dose strength meant greater profits for Purdue.

reps were under constant pressure, from headquarters, to urge doctors to “titrate” up, or increase the prescribed dose. Since OxyContin was an opioid, this was particularly relevant, because the body develops a tolerance for opioids:

Within four years of the launch celebration at the Wigwam in Arizona, OxyContin hit $1 billion in sales, surpassing the quintessential blockbuster drug of that era, Viagra.

Eventually, Michael Friedman informed the Sacklers that the principal barrier to higher sales at this point was just “product supply.” The company literally could not make OxyContin fast enough to sell it.

Nobody could say precisely where or how it started, but the first hints of it cropped up in rural Maine, in the rust belt of western Pennsylvania and eastern Ohio, in the Appalachian areas of Virginia, West Virginia, and Kentucky. The abuse spread, quickly, like some airborne virus, from one small community to the next. The regions where the problem began often had large numbers of people who were out of work, or who worked hard, manual-labor jobs, people who were disabled or chronically ill, people who were suffering from pain. As it happened, these were also precisely the kinds of regions that Steven May and other Purdue sales reps had targeted—regions that the IMS data told them would be fertile terrain for OxyContin.

Purdue had been receiving notes from its own sales force, dating as far back as 1997, not long after the initial launch of OxyContin, informing the company that abuse was happening.

Arthur Sackler rarely spoke about the toll of addiction and abuse associated with the tranquilizers that made him rich. But when he did, he made a telling distinction. People did abuse these drugs, Arthur conceded. But the real explanation for this phenomenon was not any intrinsically addictive properties of the drugs themselves. Rather, it was a reflection of the addictive personalities of the users. As evidence emerged that OxyContin was being abused, Richard Sackler adopted a similar view.

In some ways, Richard’s argument about OxyContin mirrored the libertarian position of a firearms manufacturer who insists that he bears no responsibility for gun deaths. Guns don’t kill people; people kill people. It is a peculiar hallmark of the American economy that you can produce a dangerous product and effectively off-load any legal liability for whatever destruction that product may cause by pointing to the individual responsibility of the consumer.

But prescribing a pill on a twelve-hour schedule when, for many patients, it works for only eight is a recipe for withdrawal and precisely the sorts of “peaks and troughs” that Purdue’s sales reps claimed OxyContin avoided. It is a recipe, in other words, for addiction.

By 2001, the company knew that 20 percent of all OxyContin prescriptions were being written on a more frequent dosing schedule than twelve hours.

As one pamphlet distributed by the company explained, pseudo-addiction “seems similar to addiction, but is due to unrelieved pain.” A misunderstanding of this subtle phenomenon might lead doctors to “inappropriately stigmatize the patient with the label ‘addict.’ ” 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.

But if Purdue was using the data to calibrate its marketing, Greenwood pointed out, then it should also have been able to use that data to track abuse. “Why wouldn’t you have been using this data to make sure that the Dr. Paolinos of the world weren’t wrecking the reputation of your product?”

It is in the very nature of the pharma business that there are serious rewards for changing the game, for being first. But when people started dying, the company shrank from any suggestion that it was the pioneer.

OxyContin is different.” It is “more powerful, more addictive, more widely sold, more illicitly available, and more publicized.”

the very government officials whose job it was to regulate the company and hold it to account ended up seduced by a new job at the company itself.

Everyone has a price

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.

Normally, when plaintiffs’ lawyers sue a publicly traded company, they have a “lever,” Udell would explain, which was that they could “keep the pressure up,” stoking media outrage to a point where it might begin to hurt the company’s stock price. That often meant it was cheaper for a public company to resolve a lawsuit than it would be to fight it—creating a powerful incentive to settle. But Purdue wasn’t a public company, Udell gloated. It was owned by the Sacklers, who were apparently unswayed by the bad publicity about their product. So “that’s a lever they don’t have over me.”

Eventually, the prosecutors in Abingdon would send the company nearly six hundred different subpoenas as they scoured Purdue’s confidential records, homing in on particular areas of interest.

Mountcastle worried that the company might try to beat the case not by prevailing on the merits but by getting its high-priced lawyers to go over Mountcastle’s head—and over the head of his boss, John Brownlee—to persuade the political leadership at Justice to kill it. Which is precisely what the company did.

What the investigators discovered, as they pored over this material, was that nearly every major element of the story that Purdue had been telling about its own conduct was untrue.

another reason that Purdue should have anticipated that the drug might be abused was that its own internal studies showed that the therapeutic effects of OxyContin often did not work as advertised.

Purdue had no evidence to suggest that OxyContin was less prone to abuse than other painkillers, yet the FDA allowed the company to make the claim. Then the sales reps proceeded to engineer a great con.

The year 2002 marked half a century since Arthur Sackler had purchased the small Greenwich Village patent medicine business for his brothers. The corporation that Mortimer and Raymond went on to build—and that Richard had subsequently modernized—was now an enormously lucrative enterprise that was generating well over $1 billion a year.

The family’s pride in OxyContin was undiminished by the tide of death or the wave of civil lawsuits or the federal investigation in Virginia.

September 28, 2006. It was more than a hundred pages long, the product of five years of investigation, with meticulous footnotes. The memo was an incendiary catalog of corporate malfeasance. It wasn’t just that it spelled out a litany of prosecutable misdeeds: it substantiated, in forensic detail, the knowledge and direction of those misdeeds at the highest levels of Purdue.