Empire of Pain by Patrick Keefe

A short review of this as I listened to it as an audiobook over several weeks and did not make any physical notes as I went. A good summary of the narrative can be found in Keefe’s original New Yorker essay on which the book was based, here: https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain

The focus is on the Sackler family. A fascinating story of a rags to riches family, in the first generation. Three brothers, Arthur, Mortimer and Raymond, who were all doctors. Working in hospitals they began to investigate and see the need for effective pain relief.

They created their own pharmaceutical company that sold a range of products, most notably a laxative and made moderate profits. However, their real asset was Arthur Sackler’s knack for marketing. He had worked in marketing before entering medicine and had a ‘Don Draper style intuition for the alchemy of marketing’. He targeted not the patients – but the doctors who prescribed the medicine. He also used a wide range of medical journals, many of which he started and owned himself secretly, to promote his products. In selling an anti-biotic he came up with the phrase ‘broad spectrum anti-biotic’. It’s meaningless effectively – but it sounded medical enough and doctors and patients began to buy into it.

Their first real big breakthrough product was the painkiller and anti-depressant Valium. He marketed it as a cure-all for almost everything, with one advert featuring a doctor claiming “When do we not use this drug?”. This approach worked very well and sales boomed.

The Sacklers bought a patent-medical company called Purdue Frederick. They were now an almost completely vertically integrated company. They could devise a drug, have it tested and authorised but their own patenting company, promote it in its own medical journals and sell it to hospitals with which they had connections.

The next product, and the really important one was a pain killer that used Oxycodone (Opium based). Their innovation was a time release capsule, that meant rather than patients taking 8 or 10 pills a day, they could take one large dose tablet – that would release the drug slowly throughout the day. It promised to be liberating for millions of people that suffered with chronic pain. And to an extent, it was. It was innovative. A unique selling proposition (USP). They called it OxyContin.

It proved extremely popular. However, soon the high sales began to look a bit suspicious – and they were. The Perdue sales team, working for commission, were trained to not just market this wonder pain killer to cancer patients – the original users – but to anyone suffering any type of pain. The Sacklers sent thousands of doctors on all expenses paid medical conferences in exotic locations where they would hear Purdue employees preach about the benefits. Doctors that had been on these trips were twice as likely to proscribe OxyContin than those that had not been.

It was clear that the drug was being abused. By biting through the tablet the user could get a strong opioid hit and this is what they were being used for. On the black market the pills could fetch high prices and patients would be visiting multiple doctors in multiple areas to receive as many as they could to sell on. Purdue defended its product aggressively with a sort of gun lobby message of ‘drugs don’t kill people, people do’.

However, as the patent license was nearing its end Purdue suddenly changed tack. They too came down hard on their own drug for its ease of abuse – because they had just released (with a fresh new patent) a new version – one which could not be tampered with; biting it, cutting it, boiling it – nothing could be done to it to release the maximum dose all in one go. The left it to the very last minute before releasing this version to maximise their monopoly sales of the original – it was not done to safeguard lives. As a result heroin use across the USA spiked at this moment as users addicted to OxyContin found no other way of getting their hits.

Just as that patent was about to run out the company found a loophole in US law that said patents could be extended if research was being done into the use of the drug to treat childgood illnesses – and sure enough – they invested the time and energy in trials of the drug with children looking to capitalise on this benefit. However, by this point their luck was running out and the lawmakers were being less generous with them.

The tide was turning against the Sacklers. Hundreds of thousands of people were dying across the USA from opioid abuse – and the use of opioid painkillers, most notably OxyContin was the number 1 cause of the problem. Purdue and the Sacklers have profited handsomely from causing one of the worst health and social crisis in American history. Art galleries, universities and scholarships which bore their name (and they were prolific philanthropists) were soon taken down or abolished – the name had become political poison and protests erupted outside institutions that continued to take their money. The Sacklers empire was at an end, leaving a trial of addiction, death and suffering in its wake.