A new book traces the roots of the opioid crisis through the secretive Sackler family

The family behind the OxyContin maker Purdue Pharma was already under intense legal and public scrutiny when they learned in 2019 that comedian John Oliver was planning to do a segment about them on his show, “Last Week Tonight.” But being the target of a social commentary like Oliver’s struck a chord for at least one member of the Sackler family.

“This is my son’s favorite show,” Jacqueline Sackler wrote in an email at the time. “He watches it every week with all of his friends. This situation is destroying our work, our friendships, our reputation, and our ability to function in society. And worse, it dooms my children. How is my son supposed to apply to high school in September?”

The episode is recounted in the new book, “Empire of Pain,” from author Patrick Radden Keefe. It is not just a look at the roots of the U.S. opioid crisis and the role of Purdue Pharma’s blockbuster medication OxyContin, but a deep dive into the history of the Sackler family.

Keefe retraces how one family member witnessed the power of marketing drugs directly to prescribers — well before the practice was done with OxyContin — and brings readers up to the present, as the family and company face a wave of civil litigation for their alleged role in helping ignite the addiction epidemic. The book also tracks the family’s philanthropic largesse, with millions donated to museums, universities, and other institutions, many of which have announced they will no longer take money from the family and some of which have even scrubbed the Sackler name from buildings and programs.

STAT spoke with Keefe about his book, which expands on his 2017 story about the Sacklers in the New Yorker, where he is a staff writer. Excerpts of the conversation appear below and have been lightly edited for clarity.

The Sackler family has broadly denied the charges in the civil lawsuits, and no member of the family has been charged in the investigations that led Purdue to plead guilty to federal crimes in 2007 and last year.

Purdue declined to comment on Keefe’s book.

The descendants of the Sackler brothers who built Purdue Pharma have different representatives, and a spokesman for the family of Mortimer Sackler said, “Our focus is on concluding a resolution that will provide help to people and communities in need, rather than on this book.”

In a statement, Daniel Connolly, an attorney for the family of Raymond Sackler, said: “This author has refused to correct errors in his past reporting and also blatantly violated journalistic ethics by refusing to meet with representatives for the Sackler family during the reporting of his book. Documents being released in Purdue’s bankruptcy now demonstrate that Sackler family members who served on Purdue’s board of directors acted ethically and lawfully.”

Keefe writes in his book that the Sacklers did not agree to interviews, and that “the Raymond wing opted for a more actively antagonistic role,” with legal threats and accusations of journalistic malpractice. He notes that the New Yorker’s fact-checking process turned up no errors in the magazine piece.

At this point, a lot of people might have a general sense of Purdue Pharma and who the Sacklers are. What did you learn in reporting this book that would surprise them?

There’s obviously been decades now of coverage of Purdue Pharma and OxyContin and Purdue as a business. There had, I think at times, been some ambiguity about how involved the Sackler family were in the business and how much culpability there was there. Certainly, the family has maintained in recent years that, yes, they were on the board, but really they weren’t playing that active of a role. And I think in the book, I was able to substantiate the level of very active management, and even micromanagement, of some members of the family.

One of the adjectives used most often to describe the Sacklers is “secretive,” despite the fact that their name and money is visible everywhere — at museums, universities, and so on. But through reporting and allegations in lawsuits, we’ve learned a lot more about them, and two of them even testified before Congress last year. How has the family reacted to this change in perception of them over the past few years, and what’s their strategy been to combat that?

For a long time, the strategy was to keep the family out of the headlines, to keep the family out of stories about Purdue. And they were really successful at that for many years. It’s gotten a lot harder in the last few years, probably for two big developments. One is when the lawsuits started naming individual members of the Sackler family, and then also Nan Goldin’s campaign to try and get the Sackler name taken down from various institutions.

I think you see different approaches from the Mortimer wing and the Raymond wing. They do coordinate, but they have a somewhat different approach. In my experience the Raymond wing has been very aggressive in hitting back against what they see as a blinkered narrative that has them all wrong. I think the Mortimer wing has taken a less overtly antagonistic approach when it comes to journalists trying to tell the story.

Purdue is one of a number of drug manufacturers — in addition to pharmacies and wholesalers — that are the targets of this wave of civil litigation. Beyond that, there’s questions about what the FDA did or didn’t do, and the role of prescribers as well — the point being, the roots of the opioid crisis are pretty knotty. That’s an argument Purdue and the Sacklers have tried to make in their defenses. But what to you is notable about what Purdue and the Sacklers did? Why do they deserve particular scrutiny?

Obviously the opioid crisis is incredibly complex, and there’s a huge amount of blame to go around. But Purdue was really the first mover, and Purdue and the Sacklers set out in the 1990s to change the way in which opioids were prescribed in this country, and that was a pretty explicit strategy. Before the opioid crisis ever really hit, I think they were proud of having changed the paradigm and gone out there and persuaded doctors there was “opiophobia” and that these drugs should be more widely prescribed for a wider range of conditions, for moderate pain in addition to severe pain, that they shouldn’t be a kind of nuclear solution that you graduate to. Many others followed, but I think Purdue was the first.

Opioid prescriptions have come down in recent years, and deaths attributed to prescription opioids have also come down. But the broader addiction crisis has only grown, both because of illicit opioids as well as other types of drugs, like stimulants. How do you see Purdue’s products and the Sacklers’ actions in connection to where we are now? Did it help lead to something that metastasized? 

Exactly. The opioid crisis has changed and evolved dramatically. And the Sacklers say, the vast majority of deaths and overdoses now are due to heroin and fentanyl, and of course they’re quite right. But there have been a number of studies on this, and certainly I think anyone who goes out there and talks to people who’ve struggled with opioids, you’ll learn pretty quickly that the phenomenon of prescription pills serving as an on-ramp to opioids for people who then subsequently develop an addiction to heroin or fentanyl is very common. The notion that there’s no relationship whatsoever between OxyContin and other prescription opioids, which I think pretty clearly helped create a huge population of people with an opioid use disorder, and the huge subsequent boom in heroin and fentanyl — to me that connection seems quite clear.

Purdue pleaded guilty to a federal misbranding criminal charge in 2007. And last year, the company pleaded guilty to federal criminal charges again. The charges were different, but you’ve made the point that this is a crime story of a repeat offender. What does this expose either at the governmental level or what was happening at the company? Why did this happen again?

Internally, 2007 was regarded as a speeding ticket. One detail in the book that a number of former Purdue employees told me about and they were really shocked by is that Howard Udell, who was the general counsel who pled guilty to a misdemeanor in 2007 and who was sort of forced out of the business, he remained this very revered figure at Purdue. The law library in Purdue’s headquarters was named after him and there was a portrait of him there. A number of people who worked at Purdue told me that it was this very weird thing with these mixed messages. On the one hand, there was this federal guilty plea and the company says we’re a changed company, we’re reformed, on the other hand, there’s this continued reverence for this guy who was very closely associated with the things they had done wrong. I don’t think that the company changed. I think when you looked at the types of tactics that they continued to use, I think there was a perception that they had to pay $600 million as a sort of a speeding ticket at a time when they were making billions of dollars on OxyContin and just kept going.

The second part of the answer is systemic. There was an amazing moment after the 2007 guilty plea when Arlen Specter, who was then a Republican senator from Pennsylvania, he didn’t like the idea that nobody would be going to jail. And he said, listen I worry a fine like this just becomes an expensive license for criminal misconduct. So there was a kind of conjecture that this was not going to be a deterrent. And sure enough, if you fast forward to 2020, it turns out that Arlen Specter was right.

So in addition to the guilty plea last year,  the company is also in bankruptcy proceedings. There’s a proposal for members of the family to pay some $4.3 billion to end civil litigation and to turn Purdue into a public benefit company. How would you describe what’s going on with the Sacklers at this moment, and what comes next for them?

The bankruptcy case is complicated, but I think if you back up it’s actually quite simple. The Sacklers took $10 billion out of Purdue and then pushed the company into bankruptcy. And we now know because of the company’s guilty plea that during the time when they were taking that money out, the company was committing felonies. So you now end up in this situation in which it looks as though this bankruptcy judge may end up determining what the end game is. That’s very much what the Sacklers want — they would make this contribution, Purdue would get turned into a public trust, they would get to keep the rest of their wealth, they won’t admit to any wrongdoing, and the judge would grant them a release from future civil cases.

The issue here is that four and quarter billion dollars is a lot of money. A lot of the states which are desperate for funds in order to address the crisis may be persuaded to take the deal. But there are other states resisting, and there’s this Hail Mary play on Capitol Hill with the introduction of this bill, the Sackler Act, which would deprive the judge of the ability to grant that kind of release. So it’s a little too soon to say. But it’s interesting because I think we will see the end game play out really between now and August.