Patrick Radden Keefe (2021) Empire of Pain: The Secret History of the Sackler Dynasty.

I hadn’t heard of OxyContin, nor Purdue Pharmacy (Purdue Frederick) that manufactured the opioid drug. Nor had I seen Dopesick, a Disney backed television series based on the manufacture and sale of ‘hillbilly heroin’ that ravaged America, cost 450 000 American lives (and still counting) approximately $2 trillion of collateral damage at a conservative estimate. I hadn’t heard of the Sackler family, or the ‘Cadillac high’ of OxyContin and Valium.  OxyContin was a problem foreign to me, yet familiar. No surprise that the third-generation Sacklers walked away with their billions from its manufacture and ever-increasing carousel of sales. Mortimer and Jacqueline, for example, fleeing to London, where they already had family and they could easily blend in with Russian oligarchs in the money-laundering capital of the world. Business is business in any language.

A shell game, with British tax havens, in which they’d already declared bankruptcy at home. Josh Shipton, Pennysylvania’s Attorney General declaring:

‘I truly believe they have blood on their hands.’    

A drug epidemic without a cause is a contradiction. Patrick Radden Keefe has to show the ‘taproot of the opioid epidemic’ can be traced to Purdue Fredrick. With hindsight, and millions of documents now in the public domain, the differences between probability and inevitability without being over-deterministic. He splits his investigation of the Sackler family into three parts. Patriarch, Dynasty and Legacy, which corresponds with each generation who benefitted from the sale of legal drugs.

The author, in the later stages of writing the book, received a slip with a quotation from The Great Gatsby in his mailbox.

‘They were careless people… who smashed up things and creatures and then retreated back into their money or their vast carelessness or whatever it was that kept them together, and let other people clean up their mess.’   

But there’s much to admire in the Sackler brothers. The children of Jewish immigrants from the Balkans who had come to New York. The Statue of Liberty and the promise (rescinded): ‘Give me your poor huddled masses’. Arthur was born in Brooklyn in 1913. His  brothers Mortimer and Raymond born three and four years later. They lived another kind of American dream: the rags to riches story. Their father Isaac was a proud man, and when his grocery business went bust, he reminded his sons that he still had his good name. They still had their good name. Keefe begins with that irony.

Education was the children’s route out of poverty. Arthur was the trailblazer. In the hungry thirties, when ‘Buddy, can you spare a dime?’ wasn’t just lyrics but a way of life for the majority of working people. The answer no dime and no work, yet Arthur thrived. He’d three, four, five jobs, which he bequeathed to his brothers. A polymath, he felt protective, and more of a father-figure. He was first to go to medical school. Working to pay his fees. None of the brothers found it easy. A quota system in American colleges capped the number of Jewish students. And with around sixty percent of all applicants for enrolment on medical programmes Jewish, both brothers boarded a ship and went to Glasgow to study, but had to return and finish their studies at a non-accredited medical school in Massachusetts when the second world war began in Europe.  

Arthur had already graduated from NYU in 1933, but his sharpness with money and his work ethic meant he could also pay for his brothers’ education. When Arthur lived and worked as a senior doctor at the NYU campus hospital, the chief of department showed signs of senility. His compromised judgement did not stop him performing surgery. Staff nicknamed him, ‘the Angel of Death’.

Arthur tried to stop an operation and save a woman in her thirties with a peptic ulcer, which wasn’t life-threatening. She had small children. The chief surgeon operated and she died. Arthur moved on, ‘medicine is a hierarchy, and perhaps it must be’ was his analysis.

He’d tried but failed. The problem wasn’t his. A constant theme of externalisation. Drug addiction was because of something inherently lacking in the person taking the drug. Or it was a societal problem, not a drug problem. In the same way, guns don’t kill people, people do. The answer wasn’t gun control or fewer guns but more guns. The tobacco industry used the same playbook of Constitutional rights and individual liberty. They were simply selling a product people craved. OxyContin was marketed as a drug that was similarly non-addictive. Promotional literature suggested a ceiling of one percent of people would become addicts. In the same way that Bayer, a pharmaceutical company in Germany, marketed a new wonder drug in pre-first-world-war called heroin as a cure for morphine addiction, despite being six times its strength. The ‘Angel of Death’ has multiple addresses. While a rogue surgeon might kill one or two patients a day, pharmaceutical companies can change the lives of tens of thousands.

Arthur’s genius extended beyond medicine.  He was a marketing god who made much of the family’s money through the sale of Librium and Valium. Roche manufactured both drugs, but they were sold to the public by Arthur’s marketing company, McAdams. They pegged his profits to their sales. Librium, in 1960, for example sold $20 000 worth of drugs. A year later, after Arthur’s intervention, 1.5 million prescriptions were written a month. 15 million Americans had tried it. Librium really was liberation for the drug company. Valium, from the Latin, valere, which means in good health, had a problem faced by Henry Ford. The public could have a Ford car as long as they liked it in black. Librium’s success as a minor tranquiliser to help with general anxiety meant that its generic chemical cousin Valium would eat into existing profit margins. A black and blacker coloured Ford car would compete for the same sales. Arthur differentiated between the product and expanded sales in different directions. He reframed the narrative. What was Valium for becoming what Valium not for?  Men could use it safely at work. Most medical specialists agreed it was a non-addictive quick-fix for women and children. 

His marketing company employed ‘Reds’ during the McCarthy era. Arthur recognised talent. But on his terms, and at a reduced rate. The FBI had investigated his own brothers. Raymond and Mortimer had been fired from Creedmore Psychiatric Institution in 1953 because they refused to sign a mandatory ‘loyalty pledge’ to the United States. But there was an already upward trajectory as they planned to move beyond psychiatric research and advertising. They acted as a collective. Arthur as Patriarch, and his close friend and supposed business rival, Bill Frohlich as an honorary brother. They formalised the agreement in the late forties. Richard Leather acted as their attorney. They would pool resources. When one died, the others would inherit their corporate assets and control of the businesses. Last man standing would inherit all. Then all of these businesses would pass into a charitable trust.

That was the theory of the greater good, but Arthur had only played lip service to the deal. When Frohlich died, aged 58, in September 1971, his sister and her two daughters received $6.25 million between them. Raymond and Mortimer got $37 million for his assets. Arthur who had purchased Purdue Fredrick for the brothers felt he should have received a third of their windfall. A marker of a wider split in their dynasty.  

Arthur’s first wife, even after their divorce, let him follow the maxim that was hers was his and what his was his too in his obsession with purchasing Chinese furniture and art. Philanthropy was another business. The Sackler name was added to many of the most prestigious museums, universities and colleges such as the Louvre in Paris and Oxford in England—even an escalator in London had the Sackler branding. The tranches of payment were carefully calculated for maximum publicity and accounted for in tax write-offs. Art for art sake. The Sacklers received knighthoods and numerous awards from nations such as France for their charity work. Cultural washing of their dirty business is nothing new. We see similar approaches to Manchester City and more recently Newcastle United.   

Secrecy was Arthur’s watchword. Senator Estes Kefauver was a former lawyer. He had made his reputation investigating the Mafia in the late 1950s and ran for president. His investigation of the drugs industry and monopoly pricing kept returning to Purdue Fredrick and the Sackler brothers. He noted how the Mafia relied on a coterie of lawyers, but had the same accountant, in Purdue Fredrick’s case, Louis Goldburt. The Mafia could buy off sheriffs and public servants. Drug companies had greater financial muscle they could go all the way inside Congress.

‘These drug fellows pay for a lobby that makes the steel boys look like popcorn vendors,’ a staff member claimed.

Corruption ran deeper. Arthur had perfected the art of the stitch up. His company made the product. His company competed with Frohlich’s company to provide marketing for a range of pharmaceutical products, but Arthur had help set up his rival’s company.

The Sackler’s conducted clinical trials. These should have been overseen by a public body the Food and Drug Administration (FDA). Barbara Moulton who had worked for the FDA for five years and appeared before the committee concluded they had ‘failed utterly’. Arthur had the agency examiner’s home phone number and could phone him day or night for updates. The carrot was a career changing move after with Purdue after they had left the FDA.

Marketing campaigns used FDA approval to sell their product to the gatekeepers of health, doctors and pharmacists. While extolling the virtues of those that practiced medicine, Frohlich’s data-gathering company, IMS, mined the data and showed a $20 meal voucher was enough to change prescribing behaviour. There was a gap between what doctors said and what they did. The Sacklers widened the gap not just by blitzing advertisements but clinical articles, medical journal—at face value, independent—produced by Arthur’s company, and symposiums, little get-togethers, all free and paid for by the company was standard fare. For example, The Fourth Annual Antibiotic Symposium in early 1956, the keynote speech was given by a public servant Dr Henry Welch in which he claimed a ‘third era of antibiotics’. This was used in promotional literature, printed before the event. It was so good a line it came from advertising copy. His salary at the FDA was $17 500 a year, commensurate with other senior officials. But between 1953 and 1960, investigators found Welch earned $287 142 in publishing ventures (with Arthur’s firms). He claimed his innocence but stepped down from the FDA.  

No surprise that Rudolph Giuliani that stood beside the moron’s moron Trump and claimed the 2020 US Presidential election had been rigged (an idea take from the conspiracy- theory fall-back position before his surprise victory against Hillary Clinton, which he thought he’d lose) when he stepped down from his elected position as the mayor of New York City, and went into business as a consultant, quickly found work with Purdue and OxyContin. It was the marketing of leverage and the blame game.

A top executive from Purdue put it bluntly. ‘Government officials are more comfortable that Giuliani is advising Purdue. [He] would not take an assignment with a company that he felt was acting in an improper way.’

In 2001, when he first went into business with Purdue, the former mayor of New York’s net worth was around $1 million. Five years later, in 2001, Giuliani’s reported wealth was an income of $17 million and assets of $50 million. But he failed in framing OxContin abuse as a purely law and order problem. And he failed to convince anyone but the most partisan followers of the moron’s moron that electoral fraud had taken place. His collective failures have made him a multimillionaire.

When the blinkers of medical respectability and corporate responsibility are taken off, other patterns emerge. Racism worked. African Americans were less likely to be prescribed OxyContin. But in the war against drugs, they were more likely to go to jail. Especially, after OxyContin, heroin became the drug of choice.

Bureaucracy also works. Economists found that in five control states, where licenses for opioid medication had to be filled in triplicate, missed out on the OxyContin sales blitz. That sheltered them from the exponential growth in OxyContin overdose deaths, and they never caught up.

Money talks and money walks. We’ve been here before. Writing is an act of empathy. In F. Scott Fitzgerald’s The Great Gatsby, the character Tom Buchanan, for example, is old money and enormously wealthy with property in New York. He’s reading The Rise of the Coloured Empires, when he meets his wife, Daisy’s cousin, the narrator, Nick Carraway. Buchanan isn’t much of a reader, but in the vanguard of the great replacement theory. He has other ideas, none of which are his own. But he’s just the man to tell how it is. And is highly moral, especially where the lower classes are concerned. Meyer Wolfshein, because he was Jewish, in Buchanan’s book was ‘a common swindler’. He liked to gawp at a good wreck. He knew he’d always be able to walk away.The Sacklers are third-generation money, but old ideas die hard, and then sprout back to life in new bodies.  The taproot of the opioid epidemic in America lies rotten in the grave.