Empire of Pain
                                                   Patrick Radden Keefe
                                              Doubleday, 560 pages, 2021

I am very skeptical that it is possible to read Patrick Radden Keefe’s Empire of Pain and come away with anything other than a deeply cynical perspective on government, the pharmaceutical industry, law enforcement, and the legal profession. Nominally about “the secret history of the Sackler dynasty”—a Big Pharma family whose actions helped usher in our opioid crisis—the book’s significance goes far beyond that.

Keefe’s fascination with family dynamics explains why he chose to focus on the Sackler dynasty—on the origins of their fantastic wealth and the lengths to which they would go to maintain and increase their predominance in the pharmaceutical industry. Precisely where the family’s billions came from was a mystery until relatively recently (a gap in our knowledge that of course did not stop the Smithsonian, the Metropolitan Museum of Art, the Guggenheim Museum, the Museum of Natural History, and countless universities from accepting millions in donations from the family). Empire of Pain details the measures the Sacklers were willing to take to distance their family name from any conversation involving their company, Purdue Pharma, and their “wonder drug,” OxyContin.

Through his signature style and exhaustive reporting, Keefe recreates intimate conversations between Sackler family members, discussions at board meetings, and preparation for depositions and congressional testimony between attorneys for Purdue Pharma. The reading feels fly-on-the-wall, listening in on corporate maneuvers and intra-family drama. But although these machinations are riveting, this book would not present as so momentous without a signature bombshell from Keefe.

In Say Nothing, Keefe’s previous investigative report into the murder of Jean McConville, a single mother of 10 children, among the backdrop of The Troubles in Northern Ireland, the jaw-dropper was that Gerry Adams (diplomatic statesman, according to his loyal supporters in Belfast) was very likely closely involved in McConville’s unconscionable murder. While Adams’s legacy is undoubtedly complex, if these allegations are proven out, there will be far less room for a debate on his memory.

In Empire of Pain, the revelation comes very shortly after Purdue Pharma—that is to say, the Sackler family, who were extremely involved in the day-to-day operations of Purdue Pharma and comprised much of its board—began marketing OxyContin in 1996.

Purdue manufactured OxyContin (a pure, undiluted serving of the opioid Oxycodone surrounded by a patented “coating” that would theoretically time-release the medication steadily over 12 hours) with the intent of providing much-needed relief to the tens of millions of Americans who suffered from chronic pain. There were several within the Sackler family who were elated with this scientific breakthrough, and for pro-social, not merely financial, reasons.

Nonetheless, as Keefe documents, the company was well-aware of the addictiveness of its wonder drug. As Keefe makes clear, Purdue’s lawyers and representatives repeatedly lied before congressional committees and in other depositions. He further shows that the company—at the urging of many within La Famiglia Sackler—engaged in a dizzying display of bribery and intimidation in an effort to silence the Department of Justice, the Food and Drug Administration, and anyone else whose concerns posed a challenge.

Reading Empire of Pain, one feels like Mark Ruffalo in Spotlight muttering audibly: “They knew! And they let it happen!” So many people—government bureaucrats, prosecutors, doctors, salespeople, pharmacists, and most importantly, members of the Sackler family—knew what was happening. And yet nothing was done to curb the flood of OxyContin. Keefe provides a detailed exposure of the rich web of corruption and collusion that allowed the unrelenting proliferation of the drug and ushered in the opioid crisis as we know it—450,000 dead and counting, innumerable others whose lives are wrecked.

Arthur Sackler, the eldest of the three Sackler brothers from the first generation and the unofficial patriarch of the empire, began to rewrite the rules of the pharmaceutical game at the outset of his career in the 1950s. In order to support the medication his pharmaceutical company was tasked to market, Arthur created advertising materials with completely fabricated medical professionals touting the benefits of his drugs. He was caught red-handed, and upon further investigation, was implicated in a scandalous quid-pro-quo arrangement with the Director of Antibiotic Research at the FDA, Henry Welch.

On a tip from a source, Welch was questioned about any improprieties or financial arrangements with the Sackler family. “Where my income comes from is my own business,” Welch angrily retorted. A strange response from a public servant, whose position within the FDA should have precluded him from using his perch to solicit financial favors from companies under his regulatory ambit.

Nonetheless, it was reported shortly after that Arthur’s company paid Welch nearly $300,000 (at a time when Welch’s annual salary was merely $17,500) in exchange for Welch to promote Arthur’s drugs in speeches and in other ways. Although Welch resigned in infamy after this arrangement was publicized, Arthur Sackler remained unpunished and undeterred, with a fresh outlook on how to tilt the tables in his family’s favor.

The lessons learned from this initial corrupt endeavor with the FDA in 1959 laid the foundation for Arthur’s siblings and their progeny in the years to come. When faced with adversity, the Sackler brothers and their children would simply conquer it through financial incentive, intimidation, or sheer will.

This blasé attitude towards ethical constraints and legal mores became emblematic of the Sackler family’s dealings. Richard Sackler, eldest son of Raymond Sackler, the youngest of the three Sackler boys from the first generation, is introduced on the first page of the book’s second part. Richard is described as an eccentric and voracious young man, who, when he finished medical school, began working at the family business in Connecticut as an assistant to his father. He eventually became head of research and development as well as head of marketing, until in 1995 when he became fixated on the potential of OxyContin and how the drug could garner FDA approval and be brought to market.

Just like his uncle, Richard was faced with a dilemma: follow the notoriously complex and stringent process of applying for FDA approval—including conducting clinical trials, negotiations with the FDA over dosages and intended use, and other minutiae—or find an unethical and inappropriate workaround. For someone who had spent his entire life learning from his father and uncles how to exploit the system, the choice was plain.

As of today, it is unclear exactly how the FDA approval for OxyContin transpired, but this series of events happened immediately after OxyContin was approved for market:

(1) The verbiage of the package insert of OxyContin (a huge point of contention in negotiations between pharmaceutical companies and the federal government) kept the precise language proposed by Purdue—even falsely stating that the drug was less addictive than other comparable analgesics

(2) Curtis Wright, the FDA examiner who oversaw the FDA approval granted to OxyContin, abandoned his position at the FDA.

(3) Within two years of his departure from the FDA, Wright joined Purdue Pharma as an employee with a salary of $400,000 per year.

This was just the beginning. U.S. Attorney Jay McCloskey of Maine, Attorney General Richard Blumenthal of Connecticut, Assistant U.S. Attorneys Randy Ramseyer and Rick Mountcastle from the Western District of Virginia, and Attorney General Greg Stumbo of Kentucky (among others) all pursued legal action against Purdue Pharma. Lawsuit after lawsuit was filed in dozens of jurisdictions throughout the country. Most of these cases were either dismissed on procedural grounds, or settled out of court for an amount far lower than anticipated.

In these cases, the Sackler family consistently outflanked their opposition by flexing their financial prowess, hiring and deploying credible and influential spokespeople, and ingratiating themselves with the higher-ups who had the authority to quash any investigation and criminal proceeding that ran counter to Purdue’s wishes.

The most egregious example of this high-stakes power-play from Purdue came in response to the lawsuit filed in the Western District of Virginia by John Brownlee. The case followed years of investigation and interviews conducted by Randy Ramseyer and Rick Mountcastle, and it became apparent to Purdue that it was going to proceed to trial, placing perhaps the company and its investors in financial and criminal jeopardy. This, for the Sacklers, wouldn’t do. Rather than visit tiny Abingdon, Virginia, to conference with their litigation counterparts, Purdue’s legal team went directly to Washington, DC.

The decision of the DOJ to ultimately settle with Purdue and drop the charges pending in federal court was made “behind closed doors at the Justice Department,” after boxing out Brownlee, Ramseyer, and Mountcastle from the conversation. The junior prosecutors, who had devoted a significant portion of their career to this single sprawling matter, were understandably “apoplectic.” To this day, it is not entirely clear how the decision materialized.

But the Sacklers’ overall strategy is more common than you think, at least among defendants with endlessly deep pockets: hire attorneys who were previously employed by the DOJ or elsewhere in the federal government to now represent the people whom they previously tried hard to prosecute. It’s a grim reality of the legal, financial, and political world. Rudy Giuliani was a famed prosecutor who became a spokesman for Purdue, and Mary Jo White was the SEC Director who became general counsel for Purdue. The Sackler affair is a microcosm of the notorious “revolving door”: politicians become lobbyists, prosecutors become white-collar defense attorneys, financial watchdogs become corporate attorneys or consultants who abet the sketchy tax practices of their new clients.

The Sackler family’s direct involvement in the proliferation of opioids throughout the American market has had countless quantifiable effects on our lives. The statistics we already know about tell a pretty straightforward tale: Since 1999, over 600,000 people have died of a drug overdose involving an opioid; life expectancy decreased in multiple consecutive years for the first time in decades, mainly due to overdose deaths related to opioid abuse. But there is good reason to believe the impact will ultimately be far more pronounced than even those facts allow, and it will likely take decades to understand the true scope.

Entire communities have been ravaged, families ripped apart, loved ones dead, imprisoned, or in rehab. Take the example of Everett, Washington, where, at the height of the opioid epidemic, OxyContin was a factor in more than half of the crimes committed in the entire county. Law enforcement in Everett worked tirelessly to locate the origin of these pills which were suddenly ubiquitous, and eventually pinpointed a pain clinic in Los Angeles as the culprit.

Through their meticulous tracking of OxyContin prescribed by every medical doctor, Purdue and the Sackler family were well-aware of the “voluminous prescriptions” written by clinicians at Lake Medical, a clinic in Los Angeles that was a front for a drug ring that brought pills by the thousands into the Everett community. No doubt following the advice of their high-priced attorneys, Purdue and its executives exercised some plausible deniability by neglecting to track the ultimate landing spot for the obscene amount of pills prescribed by the clinic and by eschewing any responsibility for the rampant misuse of their product.

The manic commitment that Richard Sackler demonstrated to make his drug a success, both in terms of prestige in the pharma industry and his own wild financial gain, clearly and decisively overrode any scruples a person in his position ought to have had about what success of the sort he was seeking could do to society. As he wrote in an email to a friend: “You won’t believe how committed I am to make OxyContin a huge success. It is almost that I dedicated my life to it.”

Keefe wanted to write this story because family history and internal drama intrigues him deeply. The relationships between the three Sackler brothers, and how that strife has trickled down through the generations, is fascinating. Keefe somehow gets you to empathize, albeit mildly, with the third generation of Sacklers: wealthy beyond their wildest dreams yet coming to terms with the secretive and destructive origins of their fantastic riches. Who is to say how any individual would react in that scenario?

Ultimately, however, this is an archetypal story of good and evil. With every turning of the page is the hope that some lawsuit or other will bring the Sackler empire down like a house of cards. It is impossible to read without a palpable sense of vengefulness, of injustice, and of profound disappointment in the unscrupulous behaviors of those running Purdue Pharma, and of the minor players who appear on the periphery of this story to perpetuate the vast criminality of the Sackler family. Where is their deserved comeuppance? You beg for it as you read on.

There is no grand reveal and no accountability in the end. As of this writing, Purdue Pharma has forked over hundreds of millions of dollars in fines and settlements with the Department of Justice and several attorneys general. Yet simultaneously an estimated $10 billion has been bled from the company, directly into the coffers of the surviving members of the Sackler family. As litigation continues to stall in countless courts throughout the United States, and as the family seeks immunity from being held liable for the carnage that their opioids have wrought, it reminds you just how hard it can be to bring an empire down.