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This has to be medicine’s biggest irony: a drug made and marketed for alleviating pain ultimately became the cause of much pain and sorrow for millions of Americans. The drug in question, OxyContin, and its makers, an elusive billionaire family called the Sacklers, are the subject of Patrick Radden Keefe’s new book, An Empire of Pain: The Secret History of the Sackler Dynasty.
Part-biography, part-investigation, the book chronicles the lives of Arthur Sackler – a pioneer of medical advertising – and his two brothers, Raymond and Mortimer, all of them doctors. Arthur, the family patriarch and son of Jewish immigrants, popularised drugs such as Terramycin and Betadine in the 1950s through an ad agency called William Douglas McAdams. He helped Pfizer transform itself from a supplier of chemicals to a major player in the pharmaceutical business.
His biggest success came through marketing Valium. It would become the first $100 million drug. And its makers, the Swiss healthcare company Roche, reaped billions of dollars in revenue.
All of this was achieved through a blitzkrieg of revolutionary marketing techniques, creative advertisements and an army of salespersons. The Medical Advertising Hall of Fame would eulogise Arthur’s legacy thus: “no single individual did more to shape the character of medical advertising than the multi-talented Dr Arthur Sackler. His seminal contribution was bringing the full power of advertising and promotion to pharmaceutical marketing”.
His techniques later came under scrutiny, after an internal Pfizer document in 1954 referred to doctors as ‘prey’, i.e. as targets for the salespersons to sway and persuade. But he successfully parried these and other investigations.
Keefe’s book asserts that it was Arthur’s template for aggressive and often misleading drug-marketing techniques that his brothers and heirs carried on, through a company called Purdue Pharma, which would patent OxyContin.
OxyContin is a powerful painkiller with a high abuse potential. The German chemists who first synthesised it in 1917 gave it the non-proprietary name oxycodone. Purdue’s contribution, which allowed the company to bestow the brand name OxyContin, was to invent a controlled-released version of the drug – a feature that they advertised as being safer and less addictive. The book chronicles in painstaking detail how far this claim was from the truth.
Opioid painkillers were traditionally reserved to help cancer patients manage their pain. But Purdue planned to push OxyContin to the untapped market for other kinds of pain as well. Its marketing research department had come up with an interesting point – that many American doctors considered oxycodone to be a weak opioid. So, as Keefe writes, “If the true personality of oxycodone was misunderstood by America’s doctors, the company would not correct that misunderstanding. Instead, they would exploit it.”
Patrick Radden Keefe
Picador, April 2021
Around the same time, a cohort of American doctors were talking about how pain has long been ignored and how this needs to change. Purdue Pharma courted many of these physicians to promote the drug. Now, by the time OxyContin entered the market in 1996, the consumption of morphine had already increased to such proportions that doctors weren’t prescribing many opioids. But Purdue Pharma didn’t telent: it created a phalanx of well-trained sales representatives whose sole mission was to “sell, sell, sell OxyContin”.
The company didn’t conduct any tests to measure the addictive properties of the drug, but advertised its ‘benefits’ in conferences, at seminars and in the medical literature. And within four years of OxyContin’s release, the drug was raking in a billion dollars a year in sales. By 2004, OxyContin had become the leading drug of abuse in the US.
But from 1999 or so, multiple US cities were being hit by an upsurge of drug overdose deaths. The US Centres for Disease Control and Prevention (CDC) would call it the “first wave” of the “opioid epidemic”, which ultimately claimed the lives of 50,000 Americans between 1999 and 2019, led for large part by the abuse of OxyContin.
But as thousands of Americans battled addiction, the Sackler family refused to acknowledge any link between their own product and the health crisis that had engulfed America, while continuing to make billions in profits. Keefe’s investigation points out that as early as 1997, the company knew that people were abusing OxyContin – and had staff monitor online chat-rooms where people discussed their experiences with the drug.
To Keefe’s especial credit, his book masterfully puts into focus the unchecked commercialisation of the pharmaceutical industry. Primarily a staff writer for the New Yorker, Keefe builds on two previous works, Barry Meier’s Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic (2018), and Sam Quinones’s Dreamland: The True Tale of America’s Opiate Epidemic (2015). Keefe’s work differs in the sense that he places greed at the centre of the story, where the members of the Sackler family are quintessential characters in a parable of capitalism and avarice. He makes it a point to focus on the unbridled luxury that comes with such wealth.
For example, at a resort owned by one of the members of the Sackler family in Turks and Caicos, the staff would spray the beach with water if it got too hot. Philanthropy, that old practice of American billionaires, comes under devastating scrutiny as well. The Sacklers had their name adorned on the most prestigious museums and universities on both sides of the Atlantic. In Keefe’s words, “members of the family bestowed their name on arts and education institutions with a sort of mania. It was etched into marble, emblazoned on brass plaques, even spelled out in stained glass. There were Sackler professorships and Sackler scholarships and Sackler lecture series and Sackler prizes”.
The link between the aura of respectability attached to being patrons of many hallowed institutes and the source of the wealth that financed these ventures is what this book severs with a surgeon’s precision. Many of these institutes would end up cutting ties with the Sackler name. In 2019, Tufts University, where the Sacklers had multiple institutes and programmes named after them, released a statement: “Given the human toll of the opioid epidemic in which members of the Sackler family and their company Purdue Pharma are associated, it is clear that continuing to display the Sackler name is inconsistent with these values.”
Keefe’s work is riveting in its details. To create a story about a famously secretive family is no easy feat. He had already written a story about the family and its business in 2017. One of the attorneys representing the family said when contacted for this book, “Until Mr Keefe acknowledges (and corrects) the errors in his prior reporting for The New Yorker … we have no reason to believe Mr Keefe will give my clients a fair shake in any interview.”
As the consequences of the opioid epidemic became impossible to ignore, Purdue Pharma began to confront legal disputes in one state after the other. In fact, by the late 2000s, all 50 US states had sued the Sacklers for failing to acknowledge OxyContin’s role as an opioid. Some of these states opted for out-of-court settlements; others chose to persist in court. So, like all business entities in legal distress, the family marshalled an army of lawyers for their defence.
But in 2007, company executives pleaded guilty to criminal charges of misbranding the drug and a fine of $600 million. The Sacklers were not named in the trial, and soon after the hearings concluded, Purdue Pharma further expanded its sales force – but the ‘prestige’ the family had accrued was gone. In December 2020, at an oversight committee hearing, a member of the US house of representatives called the Sacklers an evil family and another said their actions were “sickening”.
In March 2021, the Sacklers filed for bankruptcy after agreeing to shell out $2.4 billion to settle a slew of legal suits by 2030. Multiple state-appointed lawyers in the US have opposed this strategy, saying it would shield the family from any future lawsuits and liability.
The opioid epidemic has already created a canon of distressing literature, and Keefe’s work has accomplished something that the courts could not. There may never be a true reckoning for the Sackler family, but his book throws up an immutable contradiction that the Sacklers have worked hard to set up: that they are not responsible for the crisis. As one woman who lost her son to OxyContin abuse said, “Grief from the loss of a child is not a process. It is a lifelong weight upon one’s soul – a weight for which I hold Purdue and the Sacklers responsible.”
Mohammad Anas is an assistant professor of journalism in Aligarh Muslim University.