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You’ve Never Seen the Opioid Crisis Like This Before: A Review of Empire of Pain

It’s hard to keep up with the ever-growing body of literature on the opioid crisis, which has killed nearly as many Americans in the last two decades as the Civil War and is still getting worse. We are inundated with new books and articles to read, podcasts to listen to, and documentaries and miniseries to watch. Even for experts, it’s hard to find the time to stay on every new angle of this crisis.

So, take it from me, a historian of opioids: if you want to learn how one family and their company caused arguably the biggest ongoing public health crisis in the US, but you only have the time to read one book on the subject, it should be Empire of Pain: The Secret History of the Sackler Dynasty.

Cover image for Empire of Pain featuring a Greek column.
Empire of Pain: The Secret History of the Sackler Dynasty by Patrick Radden Keefe is out now. (Courtesy Penguin Random House)

Patrick Radden Keefe’s chilling account of how the Sackler family caused the opioid crisis will keep you up at night, angrily stewing about how a few bad actors could possibly trigger so much pain and suffering and pretty much get away with it all. Indeed, some experts are skeptical about simplistic origin stories that pin it all on Purdue Pharmaceuticals, the Sackler family’s company. I am sympathetic to that view – I’ve argued elsewhere that we need to understand the structural explanations for this crisis. Even so, reading Empire of Pain has left me pretty much convinced that the Sacklers and their wonder drug, Oxycontin, should rightfully bear much of the blame for the opioid crisis.

Here are the facts, as Keefe tells it:

In Depression-era New York City, the first generation of the Sackler dynasty, ambitious Arthur and his brothers Raymond and Mortimer, set out to move up in the world by accumulating wealth and social prominence. They earned MDs, bought an aging patent medicine company (which they eventually renamed Purdue Pharma), founded an advertising agency and a medical trade publication, and began splitting their time between clinical and research psychiatry and pharmaceutical advertising. The Sackler brothers cut their teeth marketing some of the 20th century’s biggest miracle drugs, including Librium and Valium, which revolutionized psychiatry in the 1950s and ’60s.

Arthur, in particular, had a penchant for making loads of money, which he used to reinvent himself, not as a psychiatrist-turned-shady adman who habitually cheated on his wives, but as a respected Manhattan socialite. But the Sackler brothers did not run their nascent empire above the board. Keefe unpacks how they fabricated clinical evidence to sell pharmaceuticals, covered up numerous conflicts of interest, and engaged in various deceptive trade practices. They also made huge philanthropic donations to the Metropolitan Museum of Art, the Smithsonian, and prestigious universities such as Columbia, but with major strings attached. For example, Arthur, who had amassed one of the world’s greatest collections of Asian art, demanded and got a personal-use enclave within the Met to house his collection, before jilting the Met by donating the collection to the rival Smithsonian.

The products that made the Sacklers really rich – and not just run-of-the-mill Manhattan wealthy, but Gilded-Age-robber-baron-level rich – were Purdue’s opioids. The first was MS Contin in the 1980s. Purdue developed an innovative pill coating to time-release morphine, an old drug that was usually given via shots but that now got a new life in pill form. Purdue skirted FDA regulations and launched the drug without approval.

The Sackler family was now in the pain management business. As the next generation joined Purdue, including cousins Richard and Kathe Sackler, they perfected the first generation’s deceptive advertising practices. They also brought fresh life to another older but far more powerful opioid, Oxycodone, by applying the company’s time-release mechanism. Purdue brought Oxycontin, the now-infamous drug behind the first wave of the opioid crisis, to market in 1995.

Purdue pushed the drug hard. As Keefe shows, Purdue again lied to the FDA as well as thousands of doctors, claiming that Oxycontin was not addictive, despite possessing unequivocal internal evidence showing the opposite. Keefe unpacks the company’s ingenious but stomach-churning deceptive marketing practices in unflinching detail. For me, this section of Empire of Pain calls into question the ethics of the entire medical advertising sector. The fact that otherwise rigorously peer-reviewed journals allowed Purdue to place Oxycontin advertisements in their pages without doing enough to discover the company’s fraud is deeply troubling for me, both as a healthcare consumer and as a scholar.

In the 1990s and 2000s, legions of pain patients became addicted to Oxycontin, dying from overdoses in droves. The rest is history. I won’t give away the book’s ending, but suffice it to say that the billionaire Sacklers became one of America’s richest families by knowingly causing the addiction crisis and for years escaped any semblance of justice.

An elderly white man sits in a chair surrounded by collectible art and artifacts.
Arthur M. Sackler in his office. (Courtesy Wikimedia)

While the first of Empire of Pain’s three sections focuses on the previously untold story of Arthur Sackler and his family, much of the second and third sections consist of information already exposed over the last decade or so by a steady stream of investigative journalists and prosecutors. Keefe tells their story, too, particularly in the third section, which recounts how Purdue Pharma came crashing down in a hurricane of lawsuits. This will leave readers in anguish because, although Purdue Pharma might be bankrupt, the Sacklers themselves have managed to hold onto most of their vast blood fortune. I found a dose of satisfaction at the end of the narrative arc, however, when Keefe recounts how the Met, the Smithsonian, and various universities have “un-named” the Sacklers as donors, upending Arthur Sackler’s primordial ambition to create “a good name” for his dynasty (16).

Even if some of what’s presented in Empire of Pain is not necessarily new, the behind-the-scenes perspective that Keefe manages to achieve in his storytelling is truly eye-opening. The little vignettes that accentuate the horror of the grand narrative are what stuck with me the most – like how Purdue Pharma lawyer Howard Udell, one of the Sacklers’ most loyal defenders at the company, introduced his own secretary to Oxycontin after a car crash, then fired her once she got addicted. Reading this book is like seeing a familiar horror movie in IMAX as opposed to watching it on your cell phone on a crowded metro train. You might know how the movie ends, but you’ve never seen it up close and personal like this.

Keefe achieves this harrowing level of detail by mining Purdue’s internal emails and Sackler family correspondence and by interviewing hundreds of company employees and other witnesses. He arrays this damning evidence in such a way as to obliterate any doubt about what the Sacklers knew of Oxycontin’s addictiveness (they knew everything), when they knew it (right from the get-go, the mid-90s), and why they pushed the drug so hard, despite knowingly harming so many people (greed, pure and simple).

While Keefe’s mountain of evidence and the intimacy of his prose are Empire of Pain’s biggest strengths, at times I couldn’t help but get lost in the 400-plus pages of details. This book is not for skimming, nor is it an emotionally easy read. But with that said, it’s well worth investing the time. Read Empire of Pain if you want to learn how a single family and their company managed to get fabulously rich by causing one of the US’s worst-ever public health crises. But more importantly, read this book if you want to understand how profit in medicine corrupts medical professionals to the point that they can become perfectly willing to kill their patients, for the right price.

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