Book Review: Empire of Pain: The Secret History of the Sackler Dynasty

This book, by Patrick Radden Keefe, will make you angry, especially if you’ve lost anyone to opioid use disorder or have suffered from it yourself.

The entire book is about how the Sackler family, owners of the pharmaceutical company Purdue Pharma, ruthlessly marketed OxyContin in the face of growing opioid use disorder and opioid overdose deaths. The book details the legal maneuvers undertaken by the Sacklers and their lawyers to avoid taking responsibility, either by financial means or an admission of guilt, for OxyContin sales. Those sales primed the pump for our epidemic of opioid use disorder and death in this country.

The first one-hundred and eighty or so pages describe the family lives of the family patriarch and his three sons, along with their descendants. This background is necessary to understand their motivations, but it’s a bit boring. Basically, the immigrant patriarch worked hard and succeeded on two fronts: he became a physician and he became an excellent salesman. The second generation consisted of three sons, all of whom became physicians, but their primary occupation became making money by owning the drug company that made OxyContin. This second generation created many offspring through multiple marriages. Some members of the third generation of U.S. Sacklers went into the family business, but most went in different directions, funded by the money from the family businesses.

Back in the middle of the last century, Sackers owned the drug company that sold Librium and Valium. The latter was marketed as a non-addicting medication for anxiety and sleep.  That was a harbinger of things to come.

Other books have related the tale of how opioids came to a place of dominance in the last part of the twentieth century, with all the hubris spread about opiophobia. But this book is a tour de force about OxyContin’s role. The author has documented painstaking detail what the Sackler family and their privately-owned drug company, Purdue Pharma, did to sell OxyContin.

IN 2007, John Brownlee, a U.S. attorney for the Western District of Virginia, brought a suit against Purdue Pharma. This book describes how Purdue Pharma lawyers tried to out-maneuver Brownlee at the beginning of his investigation (and the end) by going over his head to his bosses at the Department of Justice. That failed, to some degree, and Brownlee was able to find documents showing damning evidence.

He found evidence that the company knew OxyContin could be injected, but they instructed sales reps to tell doctors that it could not be injected. Brownlee found that Purdue executives had been cozy with the FDA employees charged with keeping the public safe. The FDA employee working with Purdue was later offered a job with Purdue for a mid-six-figure salary.

Brownlee found that sales reps were routinely trained to say things to the doctors they were detailing that were known to be untrue, even finding training videos to prove it. Sales reps were required to call on doctors known to have shady prescribing practices (running pill mills) even when they voiced reservations about calling on such doctors.

Brownlee was up against some powerful attorneys for Purdue Pharma. In the end, Purdue Pharma and three executives, Friedman, Goldenheim, and Udell, pled guilty to fraudulently marketing OxyContin. Purdue paid over $600 million in fines, and the executives got three years’ probation and community service. It was a large fine, but small in relation to the billions in profits Purdue was making. And the Sackler family had no charges brought against them.

It was a valiant attempt to hold Purdue Pharma accountable, and probably a miracle that any guilty plea at all could be gotten with the degree of influence that the Sackler family appeared to have over the government. But it was a disappointing finish.

And if you thought the legal problem was enough to make the Sackler family and Purdue Pharma change their ways…you would be dead wrong. They did not.

The Sacklers and their lawyers continued to trot out tired old lies and half-truths about their part in the opioid use disorder epidemic, while continuing to aggressively market OxyContin.

This present book presents information debunking all the excuses made by the Sackler family to shroud their involvement in the U.S. opioid epidemic

First, defenders of OxyContin, Purdue Pharma, and the Sacklers still claim that OxyContin sales accounted for a small percentage of the vast amounts of pain pills prescribed early in the opioid epidemic. They say it’s unfair to place all the blame on their shoulders. Like most of their arguments, there’s a scrap of truth to their claims, but they ignore inconvenient facts. For example, as the author points out, OxyContin contained much higher doses of oxycodone than other pills made by other companies. Therefore, Purdue Pharma’s OxyContin, though only accounting for a minority of total prescription opioid pills sold, represented a much higher percentage of total milligrams sold. Each OxyContin tablet packed up to eight and even (before the 160mg tablet was taken off the market) sixteen times the opioid firepower compared to short-acting oxycodone tablets. Besides that, the Sacklers bought another drug company, Rhodes Pharmaceuticals) to make generic oxycodone just months after the 2007 verdict in Virginia. According the book, the family wanted a “landing pad” in case they ever needed a fresh start. This facility made generic versions of OxyContin, and well as immediate release oxycodone. It became the seventh-largest manufacturer of opioids in the U.S. But the Sacklers didn’t acknowledge this to the public.

Second, the Sackler family has claimed in the past that their liability for the crimes of Purdue Pharma should be limited, since they had no role in running the company. But this book points out, repeatedly, that not only did many family members sit on the board of Purdue Pharma, but evidence shows that family members directly micromanaged sales and exhorted sales reps to use tactics to sell ever more OxyContin. Records show the Sackler family members were directly involved in running Purdue Pharma and regularly pressured sales reps to sell more OxyContin.

Third, the Sackler family and top officials at Purdue Pharma repeated said that some rogue pharmaceutical representatives of the company aggressively marketed their drug, without company knowledge or approval. OxyContin was falsely advertised as having a lower risk of addiction than other opioids. However, training videos obtained from Purdue Pharma show drug reps were trained to give inaccurate information. Indeed, that what the 2007 conviction was for: false advertising and false claims of safety.

Even when drug reps feared some physicians were running pill mills, they were told to continue calling of these doctors and to keep selling the OxyContin.

The Sacklers and their associates invented IMS, a company that collects data on doctors about what medications they prescribe, along with the quantities. This data is sold to pharmaceutical companies so they can direct sales pitches about their medications. And of course, Purdue Pharma used this information. They didn’t use it to identify bad apples, doctors who were perhaps inappropriately prescribing, though they certainly could have. They could have used their data to report overprescribing doctors to the DEA for investigation. Instead, they used their IMS data to identify areas with high rates of worker’s compensation injuries, where pain medication might be prescribed by naïve family physicians. The company felt these doctors should be targeted for OxyContin sales pitches.

The most enraging part of the book comes near the end, when the author describes more recent lawsuit settlement negotiations.

Eventually, so many states, cities, counties, hospitals, tribes, and school districts brought suits against Purdue Pharma that the Sackler family wanted to settle them all at the same time. Purdue offered to relinquish control of the drug company to a public trust and the family would donate money if they were guaranteed to be immune from future lawsuits. The total settlement would be $10-20 billion.

That’s a big number, until the details revealed that the Sackler family would only be paying from $3 billion up to a possible $4.5 billion. Given the billions the Sacklers had made over the years from the sale of OxyContin, this agreement didn’t sit well with many of the negotiators. Basically, the family said take this agreement or we will declare bankruptcy. Bankruptcy would freeze litigation against Purdue Pharma.

Talks broke down and true to their threats, Purdue Pharma declared bankruptcy. The bankruptcy judge’s rulings favored the Sacklers, particularly when he ruled that the Sacklers would also be protected by Purdue’s bankruptcy. This decision outraged many people. Our own state’s Attorney General Josh Stein said aptly, “Multi-billionaires are the opposite of bankrupt.” But the judge’s ruling stood, protecting the family from liability.

There’s so much more in the book, such as how the Sackler family’s philanthropic gifts to universities, libraries, and museums were retuned and refused, due to public outcry about where their money came from. The author suggests members of the Sackler family were upset about their charitable gifts being declined and returned. That’s truly a problem of the very wealthy.

The book contains information about brave protesters who brought the Sackler’s association with OxyContin to light and pushed venerable institutions into re-thinking gifts from such sources.

Towards the end of the book, the author asks why the Sackler family couldn’t or wouldn’t admit to their complicity in creating the opioid use disorder challenge we now face. How could they be so blind? Even if they were motivated solely by greed, at some point they must have known their lies were now brought into the sunshine. Why have they never taken a more conciliatory tone, at least pretending to have empathy for the millions of families affected specifically by OxyContin abuse?

The author said the Sackler family wouldn’t talk to him. He also said that during interviews with former Purdue Pharma employees, from executives down to sales representatives, he was struck with their “fog of denial.” He wonders if acknowledging complicity in Purdue’s and the Sackler family’s destructive acts would be too much for human conscience to bear, and so they continue to parrot the same old lies: only drug addicts abused OxyContin, only a few wayward drug reps mis-marketed OxyContin, and the company was driven only by a desire to help patients, and not by greed.

At several places in the book, the author compares the Sacklers to Big Tobacco both in their legal strategies and their refusal to admit their part in marketing a dangerous product.

After reading the book I was left feeling discouraged, disillusioned, and tired. It appears that justice for the very rich happens on a different plane, if at all. I couldn’t help but think about the physician (my blog post of May 11, 2021) indicted by the Department of Justice for – among other things – failing to do random drug screens on the patients he was treating for opioid use disorder.

None of the Sacklers have been criminally indicted for anything. Justice for the Sacklers versus justice for this physician feels…uneven…to put it mildly.

6 responses to this post.

  1. Posted by Barbara Peschke on July 6, 2021 at 1:55 am

    Thank you so much for doing a great job on the review of the book. I so appreciate it. Yes Justice for the very rich is very different than for the rest of us!

    Reply

  2. Posted by Sparky on July 6, 2021 at 3:19 am

    I don’t think the shackles family did anything wrong,when it all comes down to who’s choice it was to abuse the medication,it was the patient themselves,I promise you no dr ever prescribed a patient to snort or inject oxy,the person themselves made that choice, no dr prescribed for a patient to take10-20 pills in a 8hr span,the patient made the choice to take more than prescribed and more frequently doses,oxy actually helped many many people that had chronic pain and now they can’t even get ibuprofen 800 from a dr because of the addicts abusing the medication,and I promise you very few overdose deaths were by oxy alone,those people had multi cocktails of drugs in their systems when they OD but since they had a little oxy in there also guess what oxy got all the blame for the deaths which isn’t right.a lot of people still need oxy for pain but they can’t get it from any dr so they suffer and most commit suicide

    Reply

    • I think you’ve missed the point of the book review. In fact, one of the Sackler family’s primary defense is exactly what you have said – that people who misused their product were to blame because of their own bad behavior. But the Sacklers promoted their product as being lower risk for addiction than other opioids, with no real evidence. In other words, they lied.
      While there may be some element of choice early in the development of opioid use disorder, less choice remains after the physical dependency is established, along with the compulsion to regain the good feeling that opioids naturally bring.

      Reply

    • Posted by LynnAPRN on July 17, 2021 at 7:31 pm

      I agree with Dr. Burson and that you have missed the mark here, and in some ways, proven the point of how addictive these drugs are.

      In my twenty years of experience as a healthcare provider, I’ve not met one person who became addicted (to anything) that woke up one day and proclaimed, “Yes, I want to be a full blown addict when I grow up!”. Drugs like Oxycontin manipulate your brain, plain and simple (without getting into the neurology and chemistry of what truly occurs).

      While lower dose, immediate release meds (Norco, etc) are appropriate for acute, post operative events, and stronger extended medications for hospice/palliative care situations, it’s my opinion (after years of experience) that no patient is well served being placed on medications like Oxy for “chronic pain”. Even if you are one of few who “don’t abuse medications”, I’ve rarely met anyone who didn’t take more than prescribed at least on ONE occasion or another. Even if you take your medication every 4 to 6 hours like a “good patient”, you are in a prison you don’t realize; try to stop those drugs for 7 days and then report back. If you are “mad” at those who essentially are “bad” because “you can’t get more than ibuprofen”…. thus blaming “them” for the closure of your town pain clinic….. you have more in common with addicts than you realize.

      The book brings to the surface many important facts, and also shows how those with money and influence are “above the law”. If you promote a drug under the premise of false promises and flat out lies — you are FAR worse than any person who “snorts, injects” any substance in my book! Being physically dependent on a prescription opiod, and having to plan and center EVERY life event around your next dose means you are not much different than the person who snorts or injects the same.

      Judge less — NONE of us are perfect.

      Reply

  3. Posted by Mark Wulff on July 13, 2021 at 2:07 pm

    There is so much misinformation and total lack of understanding surrounding addiction and I wish people including addicts knew the full story.

    Sadly though, having said that, so many people have already made their minds up about addicts and all the information in the world won’t change their bigotry until they are touched by it in an intimate and painful way.

    It is so easy for non addicts to judge – addicts beat themselves up enough without anyone else getting on the bandwagon.

    The truth is that many people are addicted from their very first pill.

    One person wrote that it felt like ‘I had been touched by the hand of God’ and yet another wrote ‘When I took that first pill I knew that is how I wanted to feel for the rest of my life’.

    Addicts are people, good people who actually absolutely loathe themselves but just like the rest of us are just trying to survive, simple as that.

    The world is so hungry for kindness and compassion…..

    Reply

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