Patrick Radden Keefe’s ‘Empire of Pain’ a stunning new look at the opioid crisis

Long before the coronavirus pandemic, the United States was in the midst of a public health emergency that had killed hundreds of thousands of people over the last 25 years. And it hasn’t gone away.

Indeed, during the pandemic, deaths from drug overdoses surged — up 26 percent over the previous year, with more than 90,000 Americans dead in 2020. Some died from illegal drugs, like heroin and fentanyl, but many were killed by prescription opioids. Many of those who died from street drugs started their addictions with a doctor’s prescription.

Millions of words have been written about the opioid crisis and how to cope with it. But its history has mostly been a side note.

That history is the focus of Patrick Radden Keefe’s astounding new book, Empire of Pain: The Secret History of the Sackler Dynasty. Not only does he detail exactly how the opioid crisis began and grew — it was no accident — he drags into the spotlight one of the most secretive, wealthy and powerful families in corporate America and holds them to account.

A staff writer for the New Yorker, Keefe is a relentless reporter and a graceful, crisp writer with a gift for pacing. He won raves, and a National Book Critics Circle award, for his stunning 2019 book, Say Nothing: A True Story of Murder and Memory in Northern Ireland. That book, the harrowing story of a 1972 murder involving the Irish Republican Army, reads like a first-rate crime novel and brings terrible secrets into the light.

So Keefe’s reputation for digging into matters people don’t want uncovered preceded him. Before he even began to write Empire of Pain, the Sackler family hired a top-gun lawyer who fired off a 15-page cease-and-desist letter — the first of many attempts to threaten him, the New Yorker and his publisher, Doubleday.

That was standard operating procedure for the Sacklers; their deployment of armies of lawyers to protect their interests, not necessarily ethically, is one theme of Empire of Pain.

But it is principally a family saga that begins as a classic rags-to-riches story and takes a turn so dark that in 2020, during a congressional hearing, a congressman from Tennessee would say to one of them, “Watching you testify makes my blood boil. I’m not sure that I’m aware of any family in America that’s more evil than yours.”

The first part of the book is a biography of the three founding brothers, Arthur, Mortimer and Raymond Sackler, with Arthur taking center stage. The sons of immigrant parents, they were born in Brooklyn and came of age during the Great Depression. Arthur worked multiple jobs starting in high school, developing an entrepreneurial streak early. He worked his way through college and medical school, and his brothers followed in his footsteps.

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Practicing medicine full time wasn’t enough to keep Arthur busy. He also ran two advertising agencies (one of them as a shadow partner) and published a medical newspaper.

The Sackler brothers’ early interest in pharmaceuticals was benign. As young doctors, they worked at Creedmoor Psychiatric Center, a massive facility for mentally ill people. The brothers were dismayed by two commonly used methods for treating the patients: electroshock therapy and prefrontal lobotomy.

They came to believe that brain chemistry was a cause for many mental illnesses, and that drugs could be a better way to treat them. The success of Thorazine, used to treat psychosis, led them to purchase a small pharmaceutical company, Purdue Frederick, in 1952 for $50,000.

Arthur’s first smashing triumphs in the pharma business, though, involved drugs made by other companies. His campaign for Pfizer’s antibiotic Terramycin was credited, Keefe writes, with “revolutionizing the whole field of medical advertising.” In the early 1960s, he was the marketing genius behind the huge successes of Roche’s Valium and Librium.

Amid his other interests (and his three marriages), Arthur had developed a taste for art and antiquities, which he began collecting with his usual obsession. Soon he had some of the biggest collections in the world and was courting major museums to exhibit them. His dance with the Metropolitan Museum of Art in New York could make a book in itself; it resulted in what was called until a few years ago the Sackler Wing, which houses the ancient Temple of Dendur, brought from Egypt and reconstructed on site.

As their fortunes grew, Arthur and his brothers became major philanthropists, donating millions to museums, hospitals and universities around the world. They insisted their names be attached to those gifts — and yet they were just as adamant that their family name be obscured in relation to their business ventures. They never gave interviews about Purdue Pharma, as it came to be called, or their other businesses, even though they were intimately involved in running them.

Arthur Sackler died in 1987, long before Purdue came up with OxyContin, the pain medication to which Keefe traces the origin of the opioid crisis. So why write so much about him? For one thing, his genius for integrating different businesses — drug manufacturing, advertising, data collection on doctors and pharmacies — made his family billions of dollars.

And his penchant for secrecy, for separating the individual from the corporation, would become a family blueprint for diverting personal, financial and legal responsibility for a product with enormously destructive consequences.

The next generations of Sacklers, the brothers’ children and grandchildren, dominate the latter portion of the book. All of them jockey for power, but Raymond’s son Richard and Mortimer’s daughter Kathe play the largest roles, even arguing over the dubious honor of which of them came up with the idea for OxyContin.

When it was introduced in 1996, OxyContin was the latest in a long line of narcotic painkillers that were meant to mitigate the problem of addiction. Morphine was used during the Civil War, resulting in a quarter of a million American addicts in the postwar years. Heroin was first marketed by Bayer in 1898, touted as a nonaddictive substitute for morphine; we know how well that worked out.

To create OxyContin, Purdue Pharma’s chemists took the existing opioid oxycodone, used in small doses in drugs like Percocet, and changed two things. First, the pills were made with a time-release coating that supposedly made it impossible to abuse them by crushing so they could be snorted or injected. Second, the time-release mechanism allowed much larger doses in each pill.

It turned out to be a recipe for disaster. Yet, as addiction and overdose rates soared, Purdue expanded its sales force and urged them to target “whales,” the doctors who wrote mind-boggling numbers of prescriptions. (In one small town, doctors wrote 161 prescriptions for every 100 residents.)

And the Sacklers remained utterly sure that their drug could not become addictive if used under a doctor’s supervision. Some people, they argued, have addictive personalities, and that’s why they become addicted. Certainly the drug manufacturer has no responsibility at all.

Keefe brings the receipts, though. He reveals how the Sacklers marketed the drug, how they managed their sales force, how they manipulated federal agencies and courts, how they bent drug licensing rules, how they responded to any investigation or legal action with brutal force, how they reacted with cold indifference to all of the suffering their products caused.

He writes about how, finally, it appeared that a coalition of more than 500 cities, counties and tribes and the U.S. Department of Justice had found ways to bring the Sacklers and their company into court on civil and criminal charges. As public outcry arose, the Sackler name was stripped from museums and other institutions, their legacy of philanthropy left in ruins.

Then, in the summer of 2020, it was revealed that “attorneys for the Sacklers and Purdue had been quietly negotiating with the Trump administration for months. ... A decision had been made at high levels of the Trump administration that this matter would be resolved quickly and with a soft touch.”

The family declared corporate bankruptcy — after shipping uncounted billions overseas into their personal accounts. They negotiated a legal firewall that stipulates Sackler family members would accept no personal responsibility, nor would they issue any sort of apology.

The last stages of the story are still playing out in court. Asked in a 2020 congressional hearing whether she would apologize for “the role you played in the opioid crisis,” Kathe Sackler said, “There is nothing I can find that I would have done differently.”

Empire of Pain: The Secret History of the Sackler Dynasty

By Patrick Radden Keefe

Doubleday, 560 pages, $32.50