The Family that Built an Empire of Pain by Patrick Keefe

Rating: 7/10

Read More on AmazonRead the OriginalGet My Searchable Collection of 200+ Book Notes

The Family that Built an Empire of Pain by Patrick Keefe

Rating: 7/10

Read More on AmazonGet My Searchable Collection of 200+ Book Notes

High-Level Thoughts

A fascinating history of how the Sackler family created the modern opiate epidemic through their work at Purdue pharma, and how they've tried to cover it up. Well worth the long read.

Summary Notes

An addicted baby is now born every half hour. In places like Huntington, West Virginia, ten per cent of newborns are dependent on opioids. A district attorney in eastern Tennessee recently filed a lawsuit against Purdue, and other companies, on behalf of “Baby Doe”—an infant addict.

If present statistics are any indication, in the time it likely took you to read this article six Americans have fatally overdosed on opioids. Yet Yale appears to be in no hurry to rename its Raymond and Beverly Sackler Institute for Biological, Physical and Engineering Sciences, or its Richard Sackler and Jonathan Sackler Professorship of Internal Medicine. Perhaps it’s because the Sacklers, unlike the Calhoun family, still have a fortune to give away.

Since Purdue made it more difficult to grind OxyContin pills, prescriptions have reportedly plummeted by forty per cent. This suggests that nearly half of the original drug’s consumers may have been crushing it to get high.

This is one dreadful paradox of the history of OxyContin: the original formulation created a generation addicted to pills; the reformulation, by forcing younger users off the drug, helped create a generation addicted to heroin

the company commissioned a demographic study of Pike County and submitted it to the court, as an illustration of potential bias in the jury pool. The report was revealing in ways that Purdue may not have intended: according to the filing, twenty-nine per cent of the county’s residents said that they or their family members knew someone who had died from using OxyContin. Seven out of ten respondents described OxyContin’s effect on their community as “devastating.”

Clinicians like Paolino were breaking the law—he was sentenced to a minimum of thirty years in prison. But overprescribing generated tremendous revenue for the company. According to four people I spoke with, at Purdue such prescribers were given a name that Las Vegas casinos reserve for their most prized gamblers: whales.

Pseudo-addiction generally stopped once the pain was relieved—“often through an increase in opioid dose.”

As a pain-management pamphlet distributed by Purdue explained, pseudo-addiction “seems similar to addiction, but is due to unrelieved pain.”

the first patients to use OxyContin, in a study conducted by Purdue, were ninety women recovering from surgery in Puerto Rico. Roughly half the women required more medication before the twelve-hour mark. The study was never published. For Purdue, the business reason for obscuring such results was clear: the claim of twelve-hour relief was an invaluable marketing tool. But prescribing a pill on a twelve-hour schedule when, for many patients, it works for only eight is a recipe for withdrawal, addiction, and abuse.

Purdue’s senior medical adviser, J. David Haddox, who insisted that OxyContin was not addictive. He once likened the drug to a vegetable, saying, “If I gave you a stalk of celery and you ate that, it would be healthy. But if you put it in a blender and tried to shoot it into your veins, it would not be good.”

Almost immediately after OxyContin’s release, there were signs that people were abusing it in rural areas like Maine and Appalachia. If you ground the pills up and snorted them, or dissolved them in liquid and injected them, you could override the time-release mechanism and deliver a huge narcotic payload all at once. Perversely, users could learn about such methods by reading a warning label that came with each prescription, which said, “Taking broken, chewed or crushed OxyContin tablets could lead to the rapid release and absorption of a potentially toxic dose.”

The fact that Purdue is privately held is a major reason that the Sacklers’ connection to OxyContin has remained obscure. A publicly traded company makes periodic disclosures to its shareholders. But Purdue, Barry Meier writes, “was the Sackler family’s private domain.”

According to training materials, Purdue instructed sales representatives to assure doctors—repeatedly and without evidence—that “fewer than one per cent” of patients who took OxyContin became addicted. (In 1999, a Purdue-funded study of patients who used OxyContin for headaches found that the addiction rate was thirteen per cent.)

The marketing of OxyContin relied on an empirical circularity: the company convinced doctors of the drug’s safety with literature that had been produced by doctors who were paid, or funded, by the company.

Because OxyContin was so powerful and potentially addictive, David Kessler told me, from a public-health standpoint “the goal should have been to sell the least dose of the drug to the smallest number of patients.” But this approach was at odds with the competitive imperatives of a pharmaceutical company, he continued. So Purdue set out to do exactly the opposite.

Purdue officials discovered that many doctors wrongly assumed that oxycodone was less potent than morphine—a misconception that the company exploited.

The F.D.A. approved OxyContin in 1995, for use in treating moderate to severe pain. Purdue had conducted no clinical studies on how addictive or prone to abuse the drug might be. But the F.D.A., in an unusual step, approved a package insert for OxyContin which announced that the drug was safer than rival painkillers, because the patented delayed-absorption mechanism “is believed to reduce the abuse liability.” David Kessler, who ran the F.D.A. at the time, told me that he was “not involved in the approval.” The F.D.A. examiner who oversaw the process, Dr. Curtis Wright, left the agency shortly afterward. Within two years, he had taken a job at Purdue.

Oxycodone, which was inexpensive to produce, was already used in other drugs, such as Percodan (in which it is blended with aspirin) and Percocet (in which it is blended with Tylenol). Purdue developed a pill of pure oxycodone, with a time-release formula similar to that of MS Contin.

Humans have cultivated the opium poppy for five thousand years. The father of medicine, Hippocrates, recognized the therapeutic properties of the plant. But even in the ancient world people understood that the benevolent powers of this narcotic were offset by the perils of addiction.

The Sackler empire is a completely integrated operation in that it can devise a new drug in its drug development enterprise, have the drug clinically tested and secure favorable reports on the drug from the various hospitals with which they have connections, conceive the advertising approach and prepare the actual advertising copy with which to promote the drug, have the clinical articles as well as advertising copy published in their own medical journals, [and] prepare and plant articles in newspapers and magazines

During the sixties, Arthur got rich marketing the tranquilisers Librium and Valium. One Librium ad depicted a young woman carrying an armload of books, and suggested that even the quotidian anxiety a college freshman feels upon leaving home might be best handled with tranquilisers.

As both a doctor and an adman, Arthur displayed a Don Draper-style intuition for the alchemy of marketing. He recognized that selling new drugs requires a seduction of not just the patient but the doctor who writes the prescription.

four out of five people who try heroin today started with prescription painkillers.

Since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids.

The company funded research and paid doctors to make the case that concerns about opioid addiction were overblown, and that OxyContin could safely treat an ever-wider range of maladies.

OxyContin is a controversial drug. Its sole active ingredient is oxycodone, a chemical cousin of heroin which is up to twice as powerful as morphine.

Upon its release, in 1995, OxyContin was hailed as a medical breakthrough, a long-lasting narcotic that could help patients suffering from moderate to severe pain. The drug became a blockbuster, and has reportedly generated some thirty-five billion dollars in revenue for Purdue.

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