Viewpoint

BOOK REVIEW: EMPIRE OF PAIN BY PATRICK RADDEN KEEFE

By Frank Skilling, M.D.

The tragedy, and it’s fully that, of the ongoing opioid crisis can be placed at the feet of one family: the Sacklers. There is no other conclusion possible after one reads Empire of Pain. From the perspective of the author, if it hadn’t been for the Sacklers in their unique position atop a small pharmaceutical company that developed, promoted, and sold OxyContin®, the public health scourge our nation is living with would not have happened. There is a lot of blame to go around in this epidemic of preventable addiction and deaths, but the Sacklers are primarily responsible. A succinct explanation might be: No Sacklers, No OxyContin®, No Opioid Crisis.

Patrick Radden Keefe, a staff writer of The New Yorker and author of previous award-winning Say Nothing, has tackled the history of a family that recapitulates the American Dream played out over four generations. From their parents’ start as immigrants, the second generation Sacklers became doctors, entrepreneurs, advertisers and, most importantly, owners of a small pharmaceutical firm. After acquiring the patent rights to a long-acting opioid, their familyowned company began a campaign to treat a previously unknown condition of “chronic pain.” Claiming that thousands of Americans were suffering from such pain, the company’s promotion meshed with the new goal of treating pain as the “fifth vital sign.” The latter was an indicator that gained traction with the American Hospital Association in promoting the treatment of pain in hospital settings. Using persuasive marketing that targeted physicians, the family-owned Purdue Pharma pushed the outpatient use of long-acting opioids by mostly primary care providers. Their sales reps claimed that the long-term use of OxyContin® didn’t cause addiction. Purdue’s sales personnel blanketed the country promoting the product and its successors, always with patent protection. With cunning maneuvers, Purdue co-opted the FDA and circumvented the normal approval processes required for narcotics. Some high-ranking FDA administrators who had signed off their approval of Oxycontin® even obtained lucrative positions with Purdue after leaving their governmental supervisory positions.

Meanwhile, state boards of medicine were limited by statute and administrative procedures from investigating and closing the “pill mills” which sprang up, first in the mid-West, and later in Florida. The major pharmacy chains, including CVS, were also complicit in supplying opioids they knew were being over-prescribed or diverted into criminal drug rings. As investigations progressed, the Sackler family “lawyered up,” and used their clout at state and federal levels to conceal their involvement with the crisis. The only felony convictions were of two corporation officers, neither a family member, who “took the fall” to prevent the Sacklers from being directly implicated. After pleading guilty to minor federal drug infractions, they were barred from future positions in the pharmaceutical industry. Both were rewarded with extensive “retirement” packages. Even as one of the second generation Sacklers was pushing Purdue salespeople for more growth, the family denied knowing about the crisis or accepting any responsibility for it. The latest development is the six-billiondollar settlement with various states that the family has agreed to without accepting responsibility.

As befits the desire for legitimacy by their family, the Sacklers donated enormous sums to various universities and national charities for recognition by having buildings named after the family. The “Sackler Wing” was prominent in the National Gallery of Art in Washington, D.C.

While the Sackler immigrants started out with the concept that they must always preserve their good name, the attempt by the second-generation physician entrepreneurs to buy their exalted status and the family’s place in history through philanthropy is now being reversed. Institutions like New York’s Metropolitan Museum of Art and Yale University are removing the Sackler name from their buildings, and some universities are no longer accepting donations. The younger Sackler generations feel that they shouldn’t be stigmatized because they were not directly involved, but Keefe makes a strong point that there is plenty of blame to go around for all generations. The Sackler family has shown no remorse for its actions even as survivors of victims have faced them in open court.

In the 1970s, the ophthalmology department at the University of Miami held grand rounds that were open to all members of the local medical community. I vividly remember Dr. Ed Norton, who was always known as “The Chief,” telling a group of local ophthalmologists, “If you lose your good name in this community, you will never regain it.” Reading Empire of Pain reminded me of Mario Puzo’s The Godfather, published over 50 years ago. The similarities of an immigrant family that turned to crime and then used its great wealth to gain acceptance in society is overwhelming. The big difference is that the Corleone family killed its rivals, but the Sackler family killed its customers. It is unlikely that the multi-billiondollar settlement will wash the blood off their hands or restore honor to the family.