Last week I was staying in a cool hotel in the middle of San Francisco. When I walked out to find coffee in the morning, I came across a man with his trousers lowered as he injected himself in the groin. An older fellow nearby used the street as a toilet, adding to the human excrement on the pavement. A woman lay crashed out, hair matted over her face in the heat. Returning later in the day, passing the clusters of tents and people chasing dragons from foil, I was asked: ‘Do you want anything?’
These disturbing scenes of human despair were beside a smart shopping mall in the city with the most billionaires per capita on the planet. San Francisco saw almost three times as many people killed last year by fentanyl — the ultra-potent opioid many times stronger than heroin — than who died from Covid. And this superb exposé points the finger of blame squarely at one family: the Sacklers, who became unbelievably rich while hiding behind the facade of their private firm and seeking to launder their name with donations to art galleries, museums and universities.
The saga of America’s opioid epidemic is familiar now — even if many folk still fail to understand the full horrifying extent of the devastation, let alone how this tragic whirlwind was sparked by doctors doling out medication. There have been almost a million overdose fatalities since Purdue Pharma launched OxyContin, its supposedly safe pain relief drug, in 1996 — and the number surges each year. Yet the strength of Patrick Radden Keefe’s forensic dissection, based on dozens of interviews and the mountain of documents from court cases, is to turn a harsh spotlight on that secretive family who fostered the use of potent opioids for minor ailments, made a fortune and fuelled the addiction catastrophe.
The author’s style is recognisable after his previous book, the deservedly prize-winning Say Nothing, used a traumatised family to explore the Troubles in Northern Ireland. On one level, this is a terrific dynastic tale that begins with poor immigrants in Brooklyn and ends with entitled billionaires three generations later who whine about being social lepers. The Sacklers represent the dark side of the American dream, netting $13 billion from their nefarious activities. But Empire of Pain is also a brutal indictment of the bungling authorities who sanctioned their behaviour, the vulture-like lawyers and lobbyists who helped fend off challenges to stop them, the gullible doctors who fell for their patter and blue chip advisers such as McKinsey, blinkered by greed as they devised new tactics to flog pills.
This powerful journalism, which started with an article in the New Yorker, exposes a toxic failure of capitalism and regulation. One official involved in approving the use of OxyContin ended up on a $400,000-a-year salary with the firm one year later. Yet the Sacklers still deny responsibility, despite seeing Purdue Pharma go bust due to all the legal claims, and paying out a paltry $225 million in damages in a deal last year with the Trump administration. Your hackles rise on almost every page.
The first part revolves around Arthur, the oldest of three sons. He was a doctor but also a marketing genius who transformed advertising for pharmaceutical products. He began with the aggressive promotion of a Pfizer antibiotic, then moved on to help make Valium the most widely consumed — and abused — prescription drug in the world. Keefe argues that ‘mother’s little helper’ was the template for OxyContin, with expansion of an existing market, manipulation of medical literature and a massive, highly incentivised sales force. Arthur’s selfish character was seen in his reaction to a suicide bid by his wife, desperate to sort a divorce after he flaunted a mistress: ‘How could you do this to me?’, he asked when she recovered consciousness from an overdose.
The development and launch of OxyContin under his two brothers also echoed a previous drug firm stunt several decades earlier. During the American Civil War, morphine was widely used to treat battlefield injuries but produced a generation of addicted veterans. By the end of the 19th century, the country had a quarter of a million people hooked on the drug. So the German firm of Bayer developed a refined version called heroin, marketed as a safer alternative with all the benefits of opium but none of the drawbacks. In fact it was six times stronger and highly addictive. The firm had to stop making the drug in 1913.
The Sacklers performed a similar trick with oxycodone, another opioid synthesised in Germany. They discovered in market research that this drug had less stigma than heroin and was mistakenly seen by doctors as weaker than morphine. They found a coating they claimed would slowly release the contents over 12 hours and obviate the risk of addiction, then promoted a new pain management industry alongside their pill. But their drug was easy to abuse and, besides, as they knew, it did not really last 12 hours, so people took extra pills. Then, with breathtaking bravado, as the patent ran down Purdue offered a reformulated pill with a tougher coating as a solution to the abuse they had denied was linked to their product for so many years. Unable to rely on OxyContin to feed addiction, many users turned to street heroin pushed by the Mexican cartels, now often supplanted by fentanyl.
The Sacklers come across as staggeringly callous. Richard Sackler, a key figure who drove the aggressive marketing, testified on oath that the first time his firm became aware of any abuse was in 2000. Yet the sales team were giving warnings from the year after OxyContin was launched, while field reports were filled with hundreds of references to ‘street value’, ‘snort’ and ‘crush’. When another family member sent him a press cutting in 2001 about 59 deaths in a single state linked to their drug, he responded: ‘This is not too bad. It could have been far worse.’ Then he asked a friend why addicts deserved sympathy, since ‘they are criminals’.
One study found that four out of every five heroin users began by abusing prescription painkillers. Another found fewer overdoses in five states with tougher prescription policies. In a chilling vignette, Keefe says that lawyers preparing a case against Purdue found a 1997 picture of a high school football team in which half the players had either died or become addicted to drugs less than two decades later. I met a pharmacist from the Midwest around that time who told me she had quit her job in a chemist’s chain and gone into the medical marijuana trade since she was so sick of doling out lethal opioids prescribed by doctors.
The Sacklers sought to buy respectability with donations to elite institutions forced to carry their name in return, including Oxford University, the Serpentine Gallery and the Victoria and Albert Museum. The two central brothers in this scandal were both given honorary knighthoods by Britain, with a damehood also handed to a British-born wife. Tristram Hunt, the V&A director and a former Labour MP, shrugged off criticism and said he was ‘proud of their support’. The following year the Sacklers were compared in Congress to the Mexican drug lord Joaquin Guzman — with the big difference being that ‘El Chapo’ is serving a life sentence and was forced to forfeit $12 billion. Sadly, the Sacklers all remain free and fabulously wealthy, despite the tsunami of pain they have unleashed in their country.