This book by Patrick Radden Keefe is one that desperately needed to be written and handed as a gift to the American people. Someone needed to tie all the threads of news reports and lawsuits together, link all the headlines and investigations, and compile everything into one massive report on the impact of the Sackler Dynasty. His book is the story of how America’s overdose deaths nearly quadrupled over a twenty-five-year period. It is also a cautionary tale to policymakers who might be tempted to trust Big Pharma’s marketing claims about the addictive drugs they manufacture, including those drugs offered to treat the addictions they helped to create.

The Empire of Pain by Patrick Radden Keefe.

As I write this, America is twenty years into a burgeoning opioid epidemic. As a result, vast national resources have been marshaled to fight back against this epidemic at a cost of billions. From the offices of federal officials to civic projects in the smallest community, millions of people have been involved in trying to save the lives of those addicted to opioids. A different medical approach to treating opioid addiction using Suboxone had to be distributed to doctors who were neither trained nor experienced in dealing with addiction with the idea that this would alleviate this crisis. Millions of doses of naloxone have been manufactured and distributed to reverse as many opioid overdoses as possible.

How did we get to this point? Where did it start? There have been several good books written on this subject. This year, we have received a heroic addition to the books that help us trace the influences that landed our loved ones in rehab or stole them from our lives forever. This article looks at the invaluable service of Patrick Radden Keefe in providing intensively detailed documentation on the betrayals that brought us to this point. It is a story with effects that are both national and, for many of us, deeply personal.

Fifteen years ago, I arrived in Oklahoma to start working at a large drug rehabilitation facility. Talking to the clients of that rehab was my first intensive exposure to the opioid epidemic that was already a decade into development. I quickly learned about doctor-shopping and stealing prescription pads and even being arrested at a pharmacy drive-through while sitting in a car filled with your kids. 

Before my arrival, I honestly thought that people who became addicted were impaired or weak in some way. I quickly learned that many of the people at this rehab were wonderful, even honorable people and that what had initially felled them was taking medication exactly as prescribed by their medical doctors. It was a stunning revelation, one that I had trouble accepting for a while. Perhaps the sheer unbelievability of this harsh reality is the reason it took so long for the truth about the pharmaceutical industry, overprescribing doctors and the Sackler family to become headline news. 

But finally, it has become headline news. Not only that, but as of this year, one book after another has revealed to the American public a vast trove of information about how we got to this fearful point in our country’s history. 

A Relentless Increase of Drug-Related Deaths

I left that rehab in 2009 but I have continued to work in this field, researching and writing on this topic. Years ago, I totaled up more than two million words written on the subject of addiction and recovery. That research has exposed me to a steady diet of heartbreak. 

Along the way, I have grieved with parents who told the stories of their lost children. I agonized as I watched news headlines about individuals becoming addicted to painkillers then migrating to heroin after OxyContin was reformulated to be harder to abuse. I despaired as fentanyl began to infiltrate drug supplies, causing another surge in drug deaths. Although I supported those working in rehab as much as I could, I could only watch with a feeling of helplessness as the number of overdose deaths climbed. 

In 2006, my first year in this field, there were 26,400 drug overdose deaths in America. The Centers for Disease Control and Prevention (CDC) published the graph below under this headline: Drug overdose death rates in the United States have never been higher. This graph shows the 2006 rate of death per 100,000 people. You can see the steep increase that started soon after Purdue Pharma began its aggressive marketing of OxyContin in 1996. 

Rate of drug overdose deaths in 2006.

If all we could do is reduce our current number of overdoses to the number in 2006, we would still be saving more than 60,000 lives per year. Based on the CDC’s information, we already passed a heartbreaking milestone: more than 100,000 drug-related deaths per twelve-month period. According to my rough estimate, we probably hit that milestone on or about April 16, 2021.

I based this estimate on the CDC’s information as shown in the next graph. It provides a running twelve-month total, month by month. To clarify, the last dot on this graph shows the predicted number of overdose deaths for a twelve-month period ending in March 2021. The CDC states that the reported deaths for that period were 96,779 as of October 3,  2021. However, they estimate that the final count will eventually hit 99,106 when all reports are received. That final count is represented by the solid line. 

How could this possibly happen in our country, with our sophisticated healthcare system? With our huge law enforcement agencies? That’s the story told by Empire of Pain. It’s a story that needs to be known by every parent in America who lost a child and by every child who was orphaned by an opioid. 

Patrick Radden Keefe and Empire of Pain

With the publication of Empire of Pain, Patrick Radden Keefe joins a select group of writers and investigators who have shined a revealing light on the actions of Purdue Pharma and the Sackler family.

He follows in the footsteps of Sam Quinones, author of Dreamland: The True Tale of America’s Opiate Epidemic, published in 2015. There was Barry Meier who published Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic in 2018. Also in 2018, Beth Macy offered Dopesick (Dealers, Doctors, and the Drug Company That Addicted America) to the American public. 

Ryan Hampton added two books to this list, with American Fix: Inside the Opioid Addiction Crisis and his 2021 book, Unsettled: How the Purdue Pharma Bankruptcy Failed the Victims of the American Overdose Crisis. 

There has also been thorough coverage of the company and its contributions to America’s opioid crisis in Rolling Stone, the Los Angeles Times (a series of five extensive articles) and The New Yorker. 

After all this exposure, was there really anything else to say? Absolutely. 

Going Back to the Very Beginning

Mr. Keefe takes us back to the very beginning of this debacle, back to the birth of Arthur Sackler. Arthur was the first Sackler to delve into the pharmaceutical industry. He pioneered the aggressive marketing tactics that popularized Valium. The fact that it was addictive was overlooked as he worked on the marketing messages that would result in this drug being prescribed for any common psychological or emotional ailment. 

Before long, Valium became one of the most widely consumed drugs in the world. Even former First Lady Betty Ford admitted that she struggled with Valium use. Roche, the pharmaceutical company that manufactured the drug, was accused of overpromoting it. While Roche did the promotion, the marketing messages originated in the mind of Arthur Sackler. 

By his behavior, Arthur never manifested any responsibility for the problems associated with this overpromotion. Instead, he invented an approach that would be echoed in the family’s response to the OxyContin problems that would follow a few decades later: Blame the addictive personalities of those who were taking or abusing Valium—that was the real problem. 

This unconcern seemed to enter the DNA of the Sackler family. The next generation of Sacklers took on roles in the running of the company and the idea of personal responsibility for the effects created by OxyContin appeared never to occur to any of them. You have only to watch the eight-hour deposition of Richard Sackler, nephew of Arthur and mastermind of OxyContin’s success, to see this disregard in action. 

The Painful Timeline of OxyContin Marketing, Use, Misuse and Addiction

Year by year, Keefe lays out the timeline of the ravages created by overprescribing and addiction to OxyContin. His emphasis is not as much on the societal damage as it is on the largely-fruitless efforts of federal prosecutors to rein in the company’s marketing and the many backstories about why those efforts failed. He documents the backroom bargaining that occurred that allowed as many as a thousand sales reps to spread completely false messages to hundreds of thousands of doctors across the country. And then to continue spreading these messages for two decades. 

As an example, In Chapter 15, “God of Dreams,” Keefe describes the role of Curtis Wright, the Food and Drug Administration official in charge of approving the drug for sale and authorizing the text for the insert, that folded paper with the doctor and consumer information that accompanies the prescription. 

Richard and his team were seeking a new marketing niche for OxyContin that had previously been forbidden to opioid drugs: non-malignant pain—meaning chronic low back pain, neck pain, sprains, hangovers, arthritis, anything. If they could fit OxyContin into that niche, their riches were guaranteed. 

They had to work out a way to circumvent doctors’ bias against opioids and they found an open door in Curtis Wright. He was the one who needed to be convinced that OxyContin did not have abuse potential, that it was not addictive and that it was suitable for moderate and chronic pain. At one point, Wright wanted the insert rewritten to omit blatant marketing language. The Purdue team overcame that objection and the language stayed. 

The Purdue team worked hard to cultivate a close relationship with Wright. In fact, staff from Purdue “spent several days helping Wright compose the reviews of clinical study reports and the integrated summary of the efficacy and safety of their own drug,” according to Keefe. OxyContin was approved for use in December 1996. Within two years, Wright was working at Purdue at an annual salary of $400,000. 

The fortunes of the Purdue family soared after obtaining access to this lucrative niche, as they sold tens of billions of dollars worth of this drug over the next couple of decades. As sales soared, the company began receiving reports of people crushing and snorting the pills or dissolving them and injecting the liquid. They heard about overdose deaths climbing, especially in poor districts of West Virginia and other Appalachian areas. But their marketing never slowed. Their sales reps continued to be exhorted to focus on high-prescribing doctors to get them to prescribe even more. 

As early as 2001, these overdose deaths were making headlines. Purdue’s staff concocted one explanation after another to put the blame on those who were prescribing the drugs, those who were misusing them, anyone but themselves—the authors of those false assurances about OxyContin’s non-addictiveness. 

Lawsuits Begin to Appear… and Then Proliferate

Keefe details the efforts of John Brownlee, U.S. Attorney in Virginia to curtail the problems with a 2007 legal action that included both civil and criminal charges against the company and three executives. The action was somewhat successful and the company and executives were fined $634.5 million. The three named executives left the company but, internally, were still revered. The company paid the fines on behalf of these individuals. 

Purdue promised to clean up their act. But the changes never arrived. The same false advertising prevailed after the settlement of this action. 

It took another 13 years and thousands of lawsuits to unravel the fabric of their lengthy success. States, counties, hospitals, unions and tribes filed lawsuits seeking recompense for their costs fighting the opioid epidemic that was launched by Purdue’s marketing. Ultimately, the number of suits totaled more than 2,600. 

By the late teens, the Sackler family finally lost their prestigious social and philanthropic reputations. One by one, universities changed the names of institutions that had been funded by the Sacklers. Prominent museums rejected or refunded large donations from the family.

Between the 2007 settlement and the company’s bankruptcy filing in 2019, there were twelve years of protests by family members who lost loved ones, anti-Purdue demonstrations by activists, fancy footwork by the company to defend their actions and internal intrigue by members of the family to preserve their fortunes. Keefe tapped thousands of emails, depositions, letters and interviews to reveal these stories we saw little of in the headlines. You can find these sources documented in more than 50 pages of small-type notes at the end of the book. 

The Sackler Star Dimmed… But Has it Been Extinguished?

The family’s star rose with a fraudulent plan to put OxyContin in nearly every medicine chest in America, no matter the cost to individuals. That star dimmed as the stack of lawsuits grew. Keefe makes the point in the last chapter, “Un-Naming” (referring to the Sackler name being removed from institutions like Tufts University), that the family itself is likely to suffer little. They have already siphoned off their personal billions, nearly bankrupting the company before many of the lawsuits could be settled. It appears that none of them will ever see the inside of a jail. 

Purdue even manipulated the filing of their own bankruptcy to minimize the damage and maximize their ability to escape consequences. But the truth of corporate and familial misdeeds has been documented here in great detail. Keefe tells the story as it has never been told before, in great, well-documented depth. 

In a way, his book reads like a carefully-crafted horror movie. While reading the early pages tracing the history of the family, you know how it’s all going to turn out. You’re dreading the next chapter but you feel compelled to continue reading. Still, you’re always waiting for the ax to fall. And fall it does but not on the Sacklers. Rather, it falls on the families of America. 

Some of the facts included are utterly heartrending, like the story of a mother who brought the ashes of her deceased son to the courtroom during a 2007 hearing (page 281). As mentioned earlier, there have been several books bringing these secretive events to light but Keefe’s contribution is heroic. Every family that lost a loved one to these pills deserves to know the whole truth about how this catastrophe came about. Patrick Radden Keefe has provided a major service to this country. Now that we know in detail how we got into this fix, perhaps we can improve our national future.