“They wanted permission to be able to market [OxyContin] to kids”

As the Covid-19 pandemic begins to fizzle in the U.S., a very different kind of epidemic still rages.

We’re talking, of course, about opioid addiction.

We know what you’re thinking: I’ve heard this story before. But investigative journalist Patrick Radden Keefe’s reporting reveals that, actually, you haven’t heard half of it. The problem with prescription drugs has far older, more insidious roots in American history than all the hype and hand-wringing of the last several years indicates.

To understand what’s missing from the story, it’s useful to go over what most people do know:

• In 2017, Keefe published a story in the New Yorker about Purdue Pharma, the company that manufactures the drug OxyContin.
• OxyContin is a painkiller. Its sole ingredient is oxycodone, an opioid twice as strong as morphine.
• In the late ‘90s and early 2000s, OxyContin flooded the market and some users became addicted to it.
• The Sackler family — noted patrons of the arts and philanthropists — owned Purdue Pharma.

The Sackler family name adorns a wing at the Metropolitan Museum of Art in New York, the Guggenheim, and the Louvre in Paris. But the Sacklers’ philanthropy is perhaps best seen as a figleaf that shields the reputation of a family that made its fortune by lying to doctors about an addictive drug.

In Keefe’s new book, Empire of Pain: The Secret History of the Sackler Dynasty, the journalist tells the story of how the Sacklers came to be so rich, so influential, and, ultimately, so reviled. He does so through scores of unearthed documents and emails made public through the court system, and from interviews with those who lived inside the so-called “Empire of Pain.”

Through the book, out now, it becomes clear that today’s opioid epidemic has its roots in decisions made in the 1950s — some 70 years before Keefe started his investigations into the family.

As Keefe tells Inverse: “One of the biggest choices I made in writing the book was to devote almost a third of the book to the life of the guy who dies before OxyContin.”

“This whole story is about marketing. It’s a story about taking one thing and dressing it up to make it look like another,” Keefe says.

The interview has been edited for length and clarity.

Inverse: So much pharmaceutical advertising was shaped by Arthur Sackler and Valium. It seemed like OxyContin was a logical next step.

Patrick Radden Keefe: What was so striking to me about Arthur was that so much of what comes later happens in embryo in his story.

There is kind of a playbook that he helps create. There’s a colleague of Arthur’s in the book, who says, when it comes to medical advertising, Arthur Sackler invented the wheel.

I was just struck by so many of the resonances between the rollout of OxyContin and everything Arthur was doing in the 1950s and 1960s with Valium.

At the beginning of Arthur’s story, he’s taking a more humane approach to treating people with mental illness rather than institutionalizing them. What went wrong?

One thing I thought a lot about in the story is greed. And obviously, greed does play a really significant role in the story, but I also think idealism is part of this.

I think that’s true with Arthur and his brothers when they were trying to find a more humane solution, thinking, “What if we had a pill [to treat some of these conditions]?” I think it’s also true with the next generation of Sacklers and the launch of OxyContin.

Ultimately, they were naive, and I think reckless and irresponsible. But I do think the idea at first was: “What if we came up with an opioid that wasn’t addictive?”

The Sacklers capitalized on the idea that doctors are to be trusted and only irresponsible criminals become addicted. How successful were these stereotypes?

There’s this idea that there are different roles in society for different types of people. Again, I think it starts with Arthur because there’s this idea of the unimpeachable nature of doctors.

Arthur, on the one hand, says doctors would never be influenced by anything like advertising. On the other hand, he literally owned an advertising firm that advertises to doctors.

It’s a simple thing, but I was really struck by the fact that Purdue over the years would always say, “Well, we’re physician-owned.” There was this idea of doctors as being an example of wisdom and probity.

After the opioid crisis started, you would get ads for OxyContin with [Purdue’s Chief Medical Officer] Paul Goldenheim photographed in a white coat. Which is just so ridiculous.

“He’s not seeing patients. It’s this stagecraft where you just put a stethoscope around his neck.”

Like, he’s the chief medical officer for the company. He’s not seeing patients. It’s this stagecraft where you just put a stethoscope around his neck.

I think you see the same thing with the demonization of people who are struggling with addiction. Where it’s the opposite extreme, where you have a marginalized, stigmatized, often vilified kind of person.

I think it was very easy for Purdue and the Sacklers to scapegoat people who were abusing the drug and were addicted to the drug. To some extent, I think they still do it today.

How did the stories of people who became addicted to the drug affect how you told the story of the Sacklers?

In 2017, I published this piece about the Sacklers in the New Yorker, and I got more mail after that than I’ve ever gotten for anything. A lot of it was from people who had lost family members. Rarely would a week or two go by without me getting an email from somebody telling me their story.

Most of the books that have been written about the opioid crisis have a tendency to kind of cut away to another character, and then you follow them through the book. I wanted to take a different approach, which was to show that these people are everywhere, that you never have to go very far to find someone whose life has been upended by the drug.

Steven, a [OxyContin] sales rep, goes and calls on a doctor who is a prescriber of OxyContin and she’s just lost a relative to an OxyContin overdose.

Martha West literally works on the same floor as the Sacklers and becomes addicted to the drug.

I think there's a construct out there, like, “these dirty abuser hillbilly pill-poppers are far away from us. You know, it’s not in our backyard; it has no connection to us.”

Part of what I wanted to show was, no, that’s actually not true. If you open your eyes, these people are all around.

What for you, personally, was the most striking thing to emerge from the documents you found?

I think the big question with the Sacklers has always been what did they know and when did they know it?

OxyContin was released in 1996. Executives in the company, and even the Sacklers themselves, have told people under oath that they only learned there was any kind of problem with people misusing OxyContin through press reports in the spring of 2000.

So that was one big thing, being able to substantiate lots of lots and lots of very high-level conversations about problems, starting really in ‘97.

It shows that they lied to Congress; it shows a very deliberate strategy to fake the timeline. I think as recently as 2019, Mortimer Sackler Jr. talks about the “so-called opioid crisis.”

At the same time, you have the family starting to recalibrate their public posture. They’re starting to be publicly performative about having compassion for people who become addicted.

When the patent for Oxy was about to expire and the Sacklers didn’t want to lose profits to generics, didn’t they admit that people might misuse the drug?

They went to the FDA and told them it wasn’t safe!

They said, “No generic company should be able to make this drug; it's not safe.”

That’s a shocking thing to ask. And here’s another shocker: the FDA agreed.

They said generic makers can’t make this drug that Purdue has already been selling for 15 years at that point.

The whole patent thing was so disturbing. What do you think it reveals about the pharmaceutical industry in America?

For me, it was almost like a decoder ring, realizing that it’s all about the patent. And so there are these decisions they make that seem kind of mysterious or hard to understand the outside.

When you think about the patent timeline, it explains all kinds of things. In the book, I tell the story about when [Purdue] tried to get the pediatric indication for OxyContin.

“They wanted permission to market it to kids.”

They wanted permission to market it to kids, and at this point, the opioid crisis is already in full bloom.

There’s lots of evidence that children over the years had used and, in some cases, died from the drug. Purdue has this whole story where they say, “Oh, the FDA forced us to do that; we didn’t want to.”

“...the FDA incentivized them [to market OxyContin to kids]”

When I looked into their own internal emails and talked to some company insiders about it, it turns out the whole reason they wanted that was not because the FDA forced them to, but because the FDA incentivized them by saying, if you get the pediatric indication, we'll do six more months of patent exclusivity.

And as this person who works in the company told me, in 2011, when they were asking for it, that was a billion dollars. So they decided it was worth it.

The same thing happened with the reformulation of OxyContin — the drug was released in 1996. Reformulation doesn't happen until 2010. And just by coincidence, reformulation happened when the original patents were about to run out.

Then I find an email from [son of co-founder Mortimer] Mortimer Sackler Jr., where he literally says, “I’m worried about the patents on OxyContin. Couldn't we try and extend it by getting a pediatric indication?” It’s hard to get any more explicit than that.

What has the feedback from doctors been?

There’s a lot of blame to go around in this story. And there are a lot of doctors who are criminal doctors, many of whom went to prison. But I think there were also a lot of physicians who were kind of taken in by this.

Chronic pain is a real thing, and it’s miserable. I mentioned earlier that I get a lot of mail from relatives of people who’ve overdosed. But I also get a lot of notes from chronic pain patients who say, “Please stop writing these articles or in this book; you are making it harder for me to access the medicine that I rely on.”

That’s really hard. It’s a very hard issue. Because the drugs do provide relief.

“My position has never been that we should pull these drugs from the shelves. It’s all about over-marketing.

My position has never been that we should pull these drugs from the shelves. It’s all about over-marketing. Rather than say, “This is a really serious, powerful drug that should be reserved for a subset of patients and really severe pain where other sources of therapy haven’t worked,” what Purdue did was say, “Everybody should take it, even for moderate pain.”

And then the other aspect of it is they lied about the dangers. If you have a drug that is addictive more than one percent of the time, you shouldn’t have hundreds of sales reps going out telling doctors that less than one percent of patients become addicted. That seems to be pretty self-evident.

The last big thing is that famous tagline they came up with that Richard Sackler was so proud of: “The one to start with and the one to stay with.”

There’s a strange thing where, as a society, at the urging of Big Pharma — Purdue Pharma, but other companies as well — we learn how to get people on these drugs and we never learn how to get them off.

That’s why, even now, you’ve got these pain patients so concerned because they’re finding it harder to get prescriptions for drugs their doctors don't want them to continue on. But there’s not necessarily the medical understanding about how to taper people off these drugs or deciding how long they should take them.

These are exquisitely difficult clinical decisions. And a brute force approach of getting people off the drugs isn’t the best.

You’ve said that your wife is more likely than you to independently research a drug she’s been prescribed — that you’re more likely to trust a doctor’s orders. Has that changed after writing this book?

Temperamentally, I still have this desire to trust the experts even though my own research strongly indicates we should be skeptical of that.

There’s a weirdness about me publishing this book right now. There’s a section early in the book where I talk about Pfizer in the 1950s basically bribing the head of antibiotics at the FDA. And I got my second Pfizer shot the other day.

On the one hand, I’m making these critiques, which I think are very solid critiques, of the practices and motivations of Big Pharma, and the failures of the regulatory apparatus in the FDA.

On the other hand, I do think sometimes you need to trust the doctors. I think people should be out there getting vaccinated. It’s a compromise.

You don’t want to be blindly trusting, but you also don’t want to be so reflexively skeptical that you’re going to just turn your back on science and go it alone.