The north wing of the Metropolitan Museum of Art is a vast, airy
enclosure featuring a banked wall of glass and the Temple of Dendur, a
sandstone monument that was constructed beside the Nile two millennia
ago and transported to the Met, brick by brick, as a gift from the
Egyptian government. The space, which opened in 1978 and is known as the
Sackler Wing, is also itself a monument, to one of America’s great
philanthropic dynasties. The Brooklyn-born brothers Arthur, Mortimer,
and Raymond Sackler, all physicians, donated lavishly during their
lifetimes to an astounding range of institutions, many of which today
bear the family name: the Sackler Gallery, in Washington; the Sackler
Museum, at Harvard; the Sackler Center for Arts Education, at the
Guggenheim; the Sackler Wing at the Louvre; and Sackler institutes and
facilities at Columbia, Oxford, and a dozen other universities. The
Sacklers have endowed professorships and underwritten medical research.
The art scholar Thomas Lawton once likened the eldest brother, Arthur,
to “a modern Medici.” Before Arthur’s death, in 1987, he advised his
children, “Leave the world a better place than when you entered it.”
Mortimer
died in 2010, and Raymond died earlier this year. The brothers
bequeathed to their heirs a laudable tradition of benevolence, and an
immense fortune with which to indulge it. Arthur’s daughter Elizabeth is
on the board of the Brooklyn Museum, where she endowed the Elizabeth A.
Sackler Center for Feminist Art. Raymond’s sons, Richard and Jonathan,
established a professorship at Yale Cancer Center. “My father raised Jon
and me to believe that philanthropy is an important part of how we
should fill our lives,” Richard has said. Marissa Sackler, the
thirty-six-year-old daughter of Mortimer and his third wife, Theresa
Rowling, founded Beespace, a nonprofit “incubator” that supports
organizations like the Malala Fund. Sackler recently told W that she finds the word “philanthropy” old-fashioned. She considers herself a “social entrepreneur.”
When
the Met was originally built, in 1880, one of its trustees, the lawyer
Joseph Choate, gave a speech to Gilded Age industrialists who had
gathered to celebrate its dedication, and, in a bid for their support,
offered the sly observation that what philanthropy really buys is
immortality: “Think of it, ye millionaires of many markets, what glory
may yet be yours, if you only listen to our advice, to convert pork into
porcelain, grain and produce into priceless pottery, the rude ores of
commerce into sculptured marble.” Through such transubstantiation, many
fortunes have passed into enduring civic institutions. Over time, the
origins of a clan’s largesse are largely forgotten, and we recall only
the philanthropic legacy, prompted by the name on the building.
According to Forbes, the Sacklers are now one of America’s richest families,
with a collective net worth of thirteen billion dollars—more than the
Rockefellers or the Mellons. The bulk of the Sacklers’ fortune has been
accumulated only in recent decades, yet the source of their wealth is to
most people as obscure as that of the robber barons. While the Sacklers
are interviewed regularly on the subject of their generosity, they
almost never speak publicly about the family business, Purdue Pharma—a
privately held company, based in Stamford, Connecticut, that developed
the prescription painkiller OxyContin. Upon its release, in 1995,
OxyContin was hailed as a medical breakthrough, a long-lasting narcotic
that could help patients suffering from moderate to severe pain. The
drug became a blockbuster, and has reportedly generated some thirty-five
billion dollars in revenue for Purdue.
But OxyContin is a
controversial drug. Its sole active ingredient is oxycodone, a chemical
cousin of heroin which is up to twice as powerful as morphine. In the
past, doctors had been reluctant to prescribe strong opioids—as
synthetic drugs derived from opium are known—except for acute cancer
pain and end-of-life palliative care, because of a long-standing, and
well-founded, fear about the addictive properties of these drugs. “Few
drugs are as dangerous as the opioids,” David Kessler, the former
commissioner of the Food and Drug Administration, told me.
Purdue
launched OxyContin with a marketing campaign that attempted to counter
this attitude and change the prescribing habits of doctors. The company
funded research and paid doctors to make the case that concerns about
opioid addiction were overblown, and that OxyContin could safely treat
an ever-wider range of maladies. Sales representatives marketed
OxyContin as a product “to start with and to stay with.” Millions of
patients found the drug to be a vital salve for excruciating pain. But
many others grew so hooked on it that, between doses, they experienced
debilitating withdrawal.
Since 1999, two hundred thousand
Americans have died from overdoses related to OxyContin and other
prescription opioids. Many addicts, finding prescription painkillers too
expensive or too difficult to obtain, have turned to heroin. According
to the American Society of Addiction Medicine, four out of five people
who try heroin today started with prescription painkillers. The most
recent figures from the Centers for Disease Control and Prevention
suggest that a hundred and forty-five Americans now die every day from
opioid overdoses.
Andrew
Kolodny, the co-director of the Opioid Policy Research Collaborative,
at Brandeis University, has worked with hundreds of patients addicted to
opioids. He told me that, though many fatal overdoses have resulted
from opioids other than OxyContin, the crisis was initially precipitated
by a shift in the culture of prescribing—a shift carefully engineered
by Purdue. “If you look at the
prescribing trends for all the different opioids, it’s in 1996 that
prescribing really takes off,” Kolodny said. “It’s not a coincidence.
That was the year Purdue launched a multifaceted campaign that
misinformed the medical community about the risks.” When I asked Kolodny
how much of the blame Purdue bears for the current public-health
crisis, he responded, “The lion’s share.”
Although the Sackler
name can be found on dozens of buildings, Purdue’s Web site scarcely
mentions the family, and a list of the company’s board of directors
fails to include eight family members, from three generations, who serve
in that capacity. “I don’t know how many rooms in different parts of
the world I’ve given talks in that were named after the Sacklers,” Allen
Frances, the former chair of psychiatry at Duke University School of
Medicine, told me. “Their name has been pushed forward as the epitome of
good works and of the fruits of the capitalist system. But, when it
comes down to it, they’ve earned this fortune at the expense of millions
of people who are addicted. It’s shocking how they have gotten away
with it.”
“Dr.
Sackler considered himself and was considered to be the patriarch of
the Sackler family,” a lawyer representing Arthur Sackler’s children
once observed. Arthur was a gap-toothed, commanding polymath who trained
under the Dutch psychoanalyst Johan H. W. van Ophuijsen, whom Sackler
proudly described as “Freud’s favorite disciple.” Arthur and his
brothers, the children of Jewish immigrants from Galicia and Poland,
grew up in Brooklyn during the Depression. All three attended medical
school, and worked together at the Creedmoor Psychiatric Center, in
Queens, collectively publishing some hundred and fifty scholarly papers.
Arthur became fascinated, he later explained, by the ways that “nature
and disease can reveal their secrets.” The Sacklers were especially
interested in the biological aspects of psychiatric disorders, and in
pharmaceutical alternatives to mid-century methods such as electroshock
therapy and psychoanalysis.
But the brothers made their fortunes in commerce, rather than from
medical practice. They shared an entrepreneurial bent. As a teen-ager,
Mortimer became the advertising manager of his high-school newspaper,
and after persuading Chesterfield to place a cigarette ad he got a
five-dollar commission—a lot of money at a time when, he later said,
“even doctors were selling apples in the streets.” In 1942, Arthur
helped pay his medical-school tuition by taking a copywriting job at
William Douglas McAdams, a small ad agency that specialized in the
medical field. He proved so adept at this work that he eventually bought
the agency—and revolutionized the industry. Until then, pharmaceutical
companies had not availed themselves of Madison Avenue pizzazz and
trickery. As both a doctor and an adman, Arthur displayed a Don
Draper-style intuition for the alchemy of marketing. He recognized that
selling new drugs requires a seduction of not just the patient but the
doctor who writes the prescription.
Sackler saw doctors as
unimpeachable stewards of public health. “I would rather place myself
and my family at the judgment and mercy of a fellow-physician than that
of the state,” he liked to say. So in selling new drugs he devised
campaigns that appealed directly to clinicians, placing splashy ads in
medical journals and distributing literature to doctors’ offices. Seeing
that physicians were most heavily influenced by their own peers, he
enlisted prominent ones to endorse his products, and cited scientific
studies (which were often underwritten by the pharmaceutical companies
themselves). John Kallir, who worked under Sackler for ten years at
McAdams, recalled, “Sackler’s ads had a very serious, clinical look—a
physician talking to a physician. But it was advertising.” In 1997,
Arthur was posthumously inducted into the Medical Advertising Hall of
Fame, and a citation praised his achievement in “bringing the full power
of advertising and promotion to pharmaceutical marketing.” Allen
Frances put it differently: “Most of the questionable practices that
propelled the pharmaceutical industry into the scourge it is today can
be attributed to Arthur Sackler.”
Advertising has always entailed
some degree of persuasive license, and Arthur’s techniques were
sometimes blatantly deceptive. In the nineteen-fifties, he produced an
ad for a new Pfizer antibiotic, Sigmamycin: an array of doctors’
business cards, alongside the words “More and more physicians find
Sigmamycin the antibiotic therapy of choice.” It was the medical
equivalent of putting Mickey Mantle on a box of Wheaties. In 1959, an
investigative reporter for The Saturday Review tried to contact some of the doctors whose names were on the cards. They did not exist.
During the sixties, Arthur got rich marketing the tranquillizers
Librium and Valium. One Librium ad depicted a young woman carrying an
armload of books, and suggested that even the quotidian anxiety a
college freshman feels upon leaving home might be best handled with
tranquillizers. Such students “may be afflicted by a sense of lost
identity,” the copy read, adding that university life presented “a whole
new world . . . of anxiety.” The ad ran in a medical journal. Sackler
promoted Valium for such a wide range of uses that, in 1965, a physician
writing in the journal Psychosomatics asked, “When do we not
use this drug?” One campaign encouraged doctors to prescribe Valium to
people with no psychiatric symptoms whatsoever: “For this kind of
patient—with no demonstrable pathology—consider the usefulness of
Valium.” Roche, the maker of Valium, had conducted no studies of its
addictive potential. Win Gerson, who worked with Sackler
at the agency, told the journalist Sam Quinones years later that the
Valium campaign was a great success, in part because the drug was so
effective. “It kind of made junkies of people, but that drug worked,”
Gerson said. By 1973, American doctors were writing more than a hundred
million tranquillizer prescriptions a year, and countless patients
became hooked. The Senate held hearings on what Edward Kennedy called “a
nightmare of dependence and addiction.”
While running his advertising company, Arthur Sackler became a publisher, starting a biweekly newspaper, the Medical Tribune,
which eventually reached six hundred thousand physicians. He scoffed at
suggestions that there was a conflict of interest between his roles as
the head of a pharmaceutical-advertising company and the publisher of a
periodical for doctors. But in 1959 it emerged that a company he owned,
MD Publications, had paid the chief of the antibiotics division of the
F.D.A., Henry Welch, nearly three hundred thousand dollars in exchange
for Welch’s help in promoting certain drugs. Sometimes, when Welch was
giving a speech, he inserted a drug’s advertising slogan into his
remarks. (After the payments were discovered, he resigned.) When I asked
John Kallir about the Welch scandal, he chuckled, and said, “He got
co-opted by Artie.”
In 1952, the Sackler brothers bought a small
patent-medicine company, Purdue Frederick, which was based in Greenwich
Village and made such unglamorous staples as laxatives and earwax
remover. According to court documents, each brother would control a
third of the company, but Arthur, who was occupied with his publishing
and advertising ventures, would play a passive role. The journalist
Barry Meier, in his 2003 book, “Pain Killer: A ‘Wonder’ Drug’s Trail of Addiction and Death,”
remarks that Arthur treated his brothers “not as siblings but more like
his progeny and understudies.” Now Raymond and Mortimer, who became
joint C.E.O.s, had a company of their own.
In the early sixties, Estes Kefauver, a Tennessee senator, chaired a
subcommittee that looked into the pharmaceutical industry, which was
growing rapidly. Kefauver, who had previously investigated the Mafia,
was especially intrigued by the Sackler brothers. A memo prepared by
Kefauver’s staff noted, “The Sackler empire is a completely integrated
operation in that it can devise a new drug in its drug development
enterprise, have the drug clinically tested and secure favorable reports
on the drug from the various hospitals with which they have
connections, conceive the advertising approach and prepare the actual
advertising copy with which to promote the drug, have the clinical
articles as well as advertising copy published in their own medical
journals, [and] prepare and plant articles in newspapers and magazines.”
In January, 1962, Arthur travelled to Washington to testify before
Kefauver’s subcommittee. A panel of senators assailed him with pointed
questions, but he was a formidable interlocutor—slippery, aloof, and
impeccably prepared—and no senator landed a blow. At one point, Sackler
caught Kefauver in an error and said, “If you personally had taken the
training that a physician requires to get a degree, you would never have
made that mistake.” Quizzed about his promotion of a cholesterol drug
that had many side effects, including hair loss, Sackler deadpanned, “I
would prefer to have thin hair to thick coronaries.”
As the Sacklers grew wealthy, they became patrons of the arts. In
1974, the brothers gave the Met three and a half million dollars,
enabling the construction of the wing housing the Temple of Dendur.
Mortimer used the space for a lavish birthday party. The cake was in the
shape of the Great Sphinx, but its face had been replaced with
Mortimer’s.
In April, 1987, when Arthur Sackler was seventy-three,
he demanded that his third wife, Gillian, account for all their
household expenditures. He dictated a terse memo: “I am determined to
take command of all situations for which I personally and my estate bear
the ultimate obligation.” A month later, he had a heart attack, and
died. The family gathered for a fond memorial service at the Met, but
Arthur’s children fought bitterly with Gillian, and sparred with
Mortimer and Raymond, over the estate. They accused Gillian of trying to
steal their inheritance, and of being “inspired variously by greed,
malice, or vindictiveness toward her stepchildren.” According to the
minutes of a family meeting, Arthur’s daughter Elizabeth suggested that
he had hidden the true worth of some family investments, “because he
didn’t want Morty and Ray to think they were more valuable.” A family
lawyer told the children, “There were no absolutely white lilies here on
either side.”
Arthur’s descendants
still owned a third of Purdue Frederick, and Mortimer and Raymond were
interested in buying the stake. The company, which had moved to
Connecticut and would eventually change its name to Purdue Pharma, had
made a great deal of money under their stewardship. But such riches were
about to seem paltry. By the time the brothers made their bid, Purdue
was already developing a new drug: OxyContin.
Humans
have cultivated the opium poppy for five thousand years. The father of
medicine, Hippocrates, recognized the therapeutic properties of the
plant. But even in the ancient world people understood that the
benevolent powers of this narcotic were offset by the perils of
addiction. In his 1996 book, “Opium: A History,”
Martin Booth notes that, for the Romans, the poppy was a symbol of both
sleep and death. During the nineteen-eighties, Raymond and
Mortimer Sackler had a great success at Purdue with an innovative
painkiller called MS Contin, a morphine pill with a patented “controlled
release” formula: the drug dissolved gradually into the bloodstream
over several hours. (“Contin” was short for “continuous.”) MS Contin
became the biggest seller in Purdue’s history. But, by the late
eighties, its patent was about to expire, and Purdue executives started
looking for a drug to replace it.
One executive who was centrally involved in this effort was Raymond’s
son Richard, an enigmatic, slightly awkward man who, in the family
tradition, had trained as a doctor. Richard had joined Purdue in 1971 as
an assistant to his father, and worked his way up. His name appears on
numerous medical patents. In the summer of 1990, a Purdue scientist sent
a memo to Richard and several other colleagues, pointing out that MS
Contin could “face such serious generic competition that other
controlled-release opioids must be considered.” The memo described
ongoing efforts to create a product containing oxycodone, an opioid that
had been developed by German scientists in 1916.
Oxycodone, which
was inexpensive to produce, was already used in other drugs, such as
Percodan (in which it is blended with aspirin) and Percocet (in which it
is blended with Tylenol). Purdue developed a pill of pure oxycodone,
with a time-release formula similar to that of MS Contin. The company
decided to produce doses as low as ten milligrams, but also jumbo
pills—eighty milligrams and a hundred and sixty milligrams—whose potency
far exceeded that of any prescription opioid on the market. As Barry
Meier writes, in “Pain Killer,” “In terms of narcotic firepower,
OxyContin was a nuclear weapon.”
Before releasing OxyContin, Purdue conducted focus groups with
doctors and learned that the “biggest negative” that might prevent
widespread use of the drug was ingrained concern regarding the “abuse
potential” of opioids. But, fortuitously, while the company was
developing OxyContin, some physicians began arguing that American
medicine should reëxamine this bias. Highly regarded doctors, like
Russell Portenoy, then a pain specialist at Memorial Sloan Kettering
Cancer Center, in New York, spoke out about the problem of untreated
chronic pain—and the wisdom of using opioids to treat it. “There is a
growing literature showing that these drugs can be used for a long time,
with few side effects,” Portenoy told the Times,
in 1993. Describing opioids as a “gift from nature,” he said that they
needed to be destigmatized. Portenoy, who received funding from Purdue,
decried the reticence among clinicians to administer such narcotics for
chronic pain, claiming that it was indicative of “opiophobia,” and
suggesting that concerns about addiction and abuse amounted to a
“medical myth.” In 1997, the American Academy of Pain Medicine and the
American Pain Society published a statement regarding the use of opioids
to treat chronic pain. The statement was written by a committee chaired
by Dr. J. David Haddox, a paid speaker for Purdue.
Richard
Sackler worked tirelessly to make OxyContin a blockbuster, telling
colleagues how devoted he was to the drug’s success. The F.D.A. approved
OxyContin in 1995, for use in treating moderate to severe pain. Purdue
had conducted no clinical studies on how addictive or prone to abuse the
drug might be. But the F.D.A., in an unusual step, approved a package
insert for OxyContin which announced that the drug was safer
than rival painkillers, because the patented delayed-absorption
mechanism “is believed to reduce the abuse liability.” David Kessler,
who ran the F.D.A. at the time, told me that he was “not involved in the
approval.” The F.D.A. examiner who oversaw the process, Dr. Curtis
Wright, left the agency shortly afterward. Within two years, he had
taken a job at Purdue.
Mortimer, Raymond, and Richard Sackler launched OxyContin with one of
the biggest pharmaceutical marketing campaigns in history, deploying
many persuasive techniques pioneered by Arthur. Steven May, who joined
Purdue as an OxyContin sales representative in 1999, recalled, “At the
time, we felt like we were doing a righteous thing.” He used to tell
himself, “There’s millions of people in pain, and we have the solution.”
(May is no longer working for Purdue.) The company assembled a sales
force of as many as a thousand representatives and armed them with
charts showing OxyContin’s benefits. May attended a three-week training
session at Purdue’s headquarters. At a celebratory dinner following the
training, he was seated at a table with Richard Sackler. “I was blown
away,” he recalled. “My first impression of him was ‘This is the dude
that made it happen. He has a company that his family owns. I want to be him one day.’ ”
A
major thrust of the sales campaign was that OxyContin should be
prescribed not merely for the kind of severe short-term pain associated
with surgery or cancer but also for less acute, longer-lasting pain:
arthritis, back pain, sports injuries, fibromyalgia. The number of
conditions that OxyContin could treat seemed almost unlimited. According
to internal documents, Purdue officials discovered that many doctors
wrongly assumed that oxycodone was less potent than morphine—a misconception that the company exploited.
A 1995 memo sent to the launch team emphasized that the company did
“not want to niche” OxyContin just for cancer pain. A primary objective
in Purdue’s 2002 budget plan was to “broaden” the use of OxyContin for
pain management. As May put it, “What Purdue did really well was target
physicians, like general practitioners,
who were not pain specialists.” In its internal literature, Purdue
similarly spoke of reaching patients who were “opioid naïve.” Because
OxyContin was so powerful and potentially addictive, David Kessler told
me, from a public-health standpoint “the goal should have been to sell
the least dose of the drug to the smallest number of patients.” But this
approach was at odds with the competitive imperatives of a
pharmaceutical company, he continued. So Purdue set out to do exactly
the opposite.
Sales reps, May told me, received training in
“overcoming objections” from clinicians. If a doctor inquired about
addiction, May had a talking point ready. “ ‘The delivery system is
believed to reduce the abuse liability of the drug,’ ” he recited to me,
with a rueful laugh. “Those were the specific words. I can still
remember, all these years later.” He went on, “I found out pretty fast
that it wasn’t true.” In 2002, a sales manager from the company, William
Gergely, told a state investigator in Florida that Purdue executives
“told us to say things like it is ‘virtually’ non-addicting.”
May
didn’t ask doctors simply to take his word on OxyContin; he presented
them with studies and literature provided by other physicians. Purdue
had a speakers’ bureau, and it paid several thousand clinicians to
attend medical conferences and deliver presentations about the merits of
the drug. Doctors were offered all-expenses-paid trips to
pain-management seminars in places like Boca Raton. Such spending was
worth the investment: internal Purdue records indicate that doctors who
attended these seminars in 1996 wrote OxyContin prescriptions more than
twice as often as those who didn’t. The company advertised in medical
journals, sponsored Web sites about chronic pain, and distributed a
dizzying variety of OxyContin swag: fishing hats, plush toys, luggage
tags. Purdue also produced promotional videos featuring satisfied
patients—like a construction worker who talked about how OxyContin had
eased his chronic back pain, allowing him to return to work. The videos,
which also included testimonials from pain specialists, were sent to
tens of thousands of doctors. The marketing of OxyContin relied on an
empirical circularity: the company convinced doctors of the drug’s
safety with literature that had been produced by doctors who were paid,
or funded, by the company.
David Juurlink, who runs the division of clinical pharmacology and
toxicology at the University of Toronto, told me that OxyContin’s
success can be attributed partly to the fact that so many doctors wanted
to believe in the therapeutic benefits of opioids. “The primary goal of
medical practice is the relief of suffering, and one of the most common
types that doctors see is pain,” he said. “You’ve got a patient in
pain, you’ve got a doctor who genuinely wants to help, and now suddenly
you have an intervention that—we are told—is safe and effective.”
Watch “The Backstory”: Philip Montgomery on his portfolio about the American opioid crisis.
Keith
Humphreys, a professor of psychiatry at Stanford, who served as a
drug-policy adviser to the Obama Administration, said, “That’s the real
Greek tragedy of this—that so many well-meaning doctors got co-opted.
The level of influence is just mind-boggling. Purdue gave money to
continuing medical education, to state medical boards, to faux
grassroots organizations.” According to training materials, Purdue
instructed sales representatives to assure doctors—repeatedly and
without evidence—that “fewer than one per cent” of patients who took
OxyContin became addicted. (In 1999, a Purdue-funded study of patients
who used OxyContin for headaches found that the addiction rate was
thirteen per cent.)
Within five years of its introduction,
OxyContin was generating a billion dollars a year. “There is no sign of
it slowing down,” Richard Sackler told a team of company representatives
in 2000. The sales force was heavily incentivized to push the drug. In a
memo, a sales manager in Tennessee wrote, “$$$$$$$$$$$$$ It’s Bonus
Time in the Neighborhood!” May, who was assigned to the Virginia area,
was astonished to learn that especially skillful colleagues were earning
hundreds of thousands of dollars in commissions. One year, May’s own
sales were so brisk that Purdue rewarded him with a trip to Hawaii. As
prescriptions multiplied, Purdue executives—and the Sackler family
members on the company’s board—appeared happy to fund such
blandishments. Internal budget plans described the company’s sales force
as its “most valuable resource.” In 2001, Purdue Pharma paid forty
million dollars in bonuses.
One day, May drove
with a colleague to Lewisburg, a small city in West Virginia. They were
there to visit a doctor who had been one of May’s top prescribers. When
they arrived, the doctor was ashen. A relative had just died, she
explained. The girl had overdosed on OxyContin.
Arthur
and Mortimer Sackler each married three times, and Raymond married
once. There are fifteen Sackler children in the second generation, most
of whom have children of their own. The Sackler clan has pursued a
variety of causes and interests. In 2011, Mortimer’s widow, Theresa, who
sits on the board of Purdue, was awarded the Prince of Wales Medal for
Art Philanthropy. When the medal was conferred, Ian Dejardin, the
Sackler Director of the Dulwich Picture Gallery, remarked, “It’s going
to be difficult not to make her sound utterly saintly.” Theresa’s
daughter, Sophie, is married to the English cricket player Jamie
Dalrymple, and lives in a forty-million-dollar house in London.
Raymond’s thirty-seven-year-old grandson, David Sackler, runs a family
investment fund, and is the only member
of the third generation who sits on Purdue’s board. The fact that Purdue
is privately held is a major reason that the Sacklers’ connection to
OxyContin has remained obscure. A publicly traded company makes periodic
disclosures to its shareholders. But Purdue, Barry Meier writes, “was
the Sackler family’s private domain.”
On occasion, press accounts
about OxyContin note that profits from the drug flow to the Sacklers,
but these stories tend to depict the family as a monolith. As with any
large clan, however, there are fissures of discord. In the eighties,
Mortimer sued his ex-wife Gertraud, claiming that she had illegally
taken possession of an apartment that he owned on Fifth Avenue and had
loaned it out to a contingent of models and photographers. None of
Arthur’s descendants sit on the company’s board. At a courthouse in Long
Island, in files stemming from the family fight over Arthur’s fortune, I
came across a document indicating that, after a “protracted
negotiation,” Arthur’s estate “sold its one third interest in Purdue” to
Raymond and Mortimer.
“I have never owned
any shares in Purdue,” Michael Sackler-Berner, a Brooklyn-based
singer-songwriter who is a grandson of Arthur Sackler, told me, in an
e-mail. “None of the descendants of Arthur M. Sackler have ever had
anything to do with, or benefited from, the sale of OxyContin.”
Sackler-Berner made no mention of Librium, Valium, or MS Contin, but he
added, “Given the current controversy surrounding OxyContin, I
appreciate your clarifying the matter.”
Even though Mortimer
Sackler had a large stake in the company, he was only an occasional
presence at the Connecticut headquarters. He renounced his U.S.
citizenship in 1974, reportedly for tax reasons, and lived a flamboyant
life in Europe, shuttling among residences in England, the Swiss Alps,
and Cap d’Antibes. (In 1999, Queen Elizabeth conferred an honorary
knighthood on him, in recognition of his philanthropy.) Raymond Sackler,
who lived in Connecticut, had a more modest temperament and came to his
office at Purdue—where he was respectfully known as Dr. Raymond—every
day. John Kallir, Arthur’s former advertising colleague, recalled, “Ray
was quiet, reasonably honest, always married to the same woman. The
least interesting of the three brothers.”
Almost
immediately after OxyContin’s release, there were signs that people
were abusing it in rural areas like Maine and Appalachia. If you ground
the pills up and snorted them, or dissolved them in liquid and injected
them, you could override the time-release mechanism and deliver a huge
narcotic payload all at once. Perversely, users could learn about such
methods by reading a warning label that came with each prescription,
which said, “Taking broken, chewed or crushed OxyContin tablets could
lead to the rapid release and absorption of a potentially toxic dose.”
As more and more doctors prescribed OxyContin for an ever-greater range
of symptoms, some patients began selling their pills on the black
market, where the street price was a dollar a milligram. Doctors who
were easily manipulated by their patients—or corrupted by the money in
play—set up so-called pill mills, pain clinics that thrived on a
wholesale business of issuing OxyContin prescriptions.
The company did not pull the drug from shelves, however, or
acknowledge that it was addictive. Instead, Purdue insisted that the
only problem was that recreational drug users were not taking OxyContin
as directed. “Their rap has always been that a bunch of junkies ruined
their product,” Keith Humphreys, the Stanford professor, said. In 2001,
Michael Friedman, Purdue’s executive vice-president, testified before a
congressional hearing convened to look into the alarming increase in
opioid abuse. The marketing of OxyContin had been “conservative by any
standard,” he maintained. “Virtually all of these reports involve people
who are abusing the medication, not patients with legitimate medical
needs.”
In 2002, a twenty-nine-year-old woman from New Jersey,
Jill Skolek, was prescribed OxyContin for a back injury. One night,
after four months on the drug, she died in her sleep, from respiratory
arrest, leaving behind a six-year-old son. Her mother, Marianne Skolek
Perez, was a nurse. Distraught and bewildered, she became convinced that
OxyContin was dangerous. Perez wrote to F.D.A. officials, urging them
to append to OxyContin packaging a warning about the risk of addiction.
The
following year, Perez attended a conference on addiction at Columbia
University. A sandy-haired man named Robin Hogen, wearing a pin-striped
suit and a bow tie, was there, too. He was a communications specialist
for Purdue, and had launched a vigorous campaign to defend the drug,
warning newspapers to be careful about their coverage. “We’re going to
be watching them,” he had promised. He had also enlisted Rudolph
Giuliani, the former mayor of New York, and his associate Bernard Kerik
to preëmpt any government crackdown. “We have to be politically
Machiavellian, often, to win the day,” Hogen once said. At the Columbia
event, he was asked about Perez’s daughter. He cautioned that one should
not read into the tragedy any liability on Purdue’s part. The real
problem, he said, was Jill Skolek: “We think she abused drugs.” (Hogen
subsequently apologized for his remark. He no longer works for Purdue.)
Another speaker at the event was Purdue’s senior medical adviser, J.
David Haddox, who insisted that OxyContin was not addictive. He once
likened the drug to a vegetable, saying, “If I gave you a stalk of
celery and you ate that, it would be healthy. But
if you put it in a blender and tried to shoot it into your veins, it
would not be good.” When Haddox was walking out of the event, Perez, who
is petite and rail thin, deliberately bumped into him. Caught off
guard, Haddox staggered backward and fell, with a clatter, into a row of
folding chairs. “It was one of those Kodak moments,” Perez recalled.
“It was probably the wrong thing to do. But I loved it.”
Arthur
Sackler once wrote that “all health problems devolve upon the
individual,” and it was Purdue’s position that OxyContin overdoses were a
matter of individual responsibility, rather than the drug’s addictive
properties. In addition to people like Hogen and Haddox, the company put
forward several top executives to mount a defense, including Howard
Udell, Purdue’s general counsel, who had been a longtime legal adviser
to the Sacklers. Udell “was like Tom Hagen in ‘The Godfather,’ ” an
attorney who dealt with him told me. “Very loyal to the
family.” Udell was clearly aware, however, of the abuse potential of
OxyContin. According to court documents, his own secretary became
addicted to the drug, and was subsequently fired by Purdue.
By
2003, the Drug Enforcement Administration had found that Purdue’s
“aggressive methods” had “very much exacerbated OxyContin’s widespread
abuse.” Rogelio Guevara, a senior official at the D.E.A., concluded that
Purdue had “deliberately minimized” the risks associated with the drug.
But the company continued shifting the blame to drug abusers, creating a
public-service announcement that showed a teen-ager raiding his
parents’ medicine cabinet.
In a phone interview, Hogen told me that, for Purdue and the
Sacklers, “there was a sense almost of betrayal—how could people put the
availability of that product in jeopardy by abusing it for pleasure?”
Hogen said that the company received many letters from grateful pain
patients, thanking Purdue for “giving them their lives back.” Asked
about his reticence to acknowledge that OxyContin might be addictive,
Hogen said, “Today, addiction is broadly seen as a disease. Then, it was
not. I think our understanding of addiction has grown enormously in the
last fifteen years.”
People have known for thousands of years that opium derivatives are addictive, I said.
“You really need to talk to a clinician,” Hogen replied. “I’m not a doctor.”
J.
David Haddox is a doctor. In 2001, he told an Associated Press
reporter, “A lot of these people say, ‘Well, I was taking the medicine
like my doctor told me to,’ and then they start taking more and more and
more.” He added, “I don’t see where that’s my problem.” (Haddox, who
still works for Purdue, declined to comment.)
The truth was that
the dangers of OxyContin were intrinsic to the drug—and Purdue knew it.
The time-release formula meant that, in principle, patients could safely
ingest one giant dose every twelve hours. They could sleep through the
night—a crucial improvement over conventional painkillers, such as
morphine, which require more frequent dosing. One of Purdue’s initial
advertising campaigns featured a photograph of two little dosage cups,
one marked “8 A.M.” and the other “8 P.M.,”
and the words “Remember, Effective Relief Just Takes Two.” But internal
Purdue documents, which have emerged through litigation, show that even
before the company received F.D.A. approval it was aware that not all
patients who took OxyContin were achieving twelve-hour relief. A recent exposé by the Los Angeles Times
revealed that the first patients to use OxyContin, in a study conducted
by Purdue, were ninety women recovering from surgery in Puerto Rico.
Roughly half the women required more medication before the twelve-hour
mark. The study was never published. For Purdue, the business reason for
obscuring such results was clear: the claim of twelve-hour relief was
an invaluable marketing tool. But prescribing a pill on a twelve-hour
schedule when, for many patients, it works for only eight is a recipe
for withdrawal, addiction, and abuse. Notwithstanding Purdue’s claims,
many people who were not drug abusers—and who took OxyContin exactly as
their doctors instructed—began experiencing withdrawal symptoms between
doses. In March, 2001, a Purdue employee e-mailed a supervisor,
describing some internal data on withdrawal and wondering whether or not
to write up the results, even though doing so would only “add to the
current negative press.” The supervisor responded, “I would not write it
up at this point.”
Doctors who prescribed OxyContin were beginning to report that
patients were coming to them with symptoms of withdrawal (itching,
nausea, the shakes) and asking for more medication. Haddox had an
answer. In a 1989 paper, he had coined the term “pseudo-addiction.” As a
pain-management pamphlet distributed by Purdue explained,
pseudo-addiction “seems similar to addiction, but is due to unrelieved
pain.” The pamphlet continued, “Misunderstanding of this phenomenon may
lead the clinician to inappropriately stigmatize the patient with the
label ‘addict.’ ” Pseudo-addiction generally stopped once the pain was
relieved—“often through an increase in opioid dose.”
“When you
promote these very massive doses of opioids, the more of it that is out
there the more abuse there will be,” David Kessler said. “It’s almost
linear.” U.S. sales of OxyContin soon exceeded those of Viagra.
Everywhere the drug spread, addiction followed. To Steven May,
the sales representative in Virginia, it seemed as if the problems
associated with OxyContin were metastasizing, “like a cancer.”
According to Robin Hogen, the members of the Sackler family “were
unified in their shock that this was happening to a product they were
very proud of.” The Sacklers did not have an arm’s-length relationship
with Purdue, Hogen said: “This was an active family and an active
board.” In 1999, Richard Sackler became Purdue’s president. As the head
of a privately held company, however, he felt no pressure to be the
public face of the business, and he never appeared at forums where
people like Haddox defended Purdue. Indeed, though Sackler presided over
the tremendously successful launch of OxyContin, he has never given an
on-the-record interview about the drug. “I’ve had a lot of experience
with Purdue over the years, in different settings, but I’ve never even seen
Richard Sackler,” the addiction specialist Andrew Kolodny, who is a
frequent Purdue critic, told me. “I don’t think I’d know him if he was
standing in front of me.”
Even after it became clear that
OxyContin was being widely abused, Purdue refused to concede that it
posed risks. Company leaders worried mainly that attempts to stem
overdoses might deprive pain patients of access to the drug. “They said,
‘We need to make sure that these products are available for
patients,’ ” Hogen said. “That was their sole focus.” According to
Steven May, the sales force was instructed to ride out the controversy,
ignore abuse reports, and “sell through it.” As late as 2003, the F.D.A.
sent Purdue a warning letter about ads that “grossly overstate the
safety profile of OxyContin by not referring in the body of the
advertisements to serious, potentially fatal risks.”
In
his congressional testimony, Michael Friedman, Richard Sackler’s
deputy, said that Purdue first became aware of problems with OxyContin
only in April, 2000, after a series of press reports about people
abusing it recreationally in Maine. But Purdue didn’t need the media’s
help to know that something was seriously off with the distribution of
OxyContin. For years, it had maintained a contract with I.M.S., a
little-known company, co-founded by Arthur Sackler, that furnished its
clients with fine-grained information about the prescribing habits of
individual doctors. Purdue’s sales representatives used the data to
figure out which doctors to target.
Such data could also be used to track patterns of abuse. “They know exactly
what people are prescribing,” Kolodny said. “They know when a doctor is
running a pill mill.” At the 2001 hearing, James Greenwood, a
Pennsylvania congressman, asked Friedman whether Purdue would take any
action if, say, I.M.S. data revealed that a rural osteopath was writing
thousands of prescriptions.
Friedman replied that it was not up to Purdue to assess “how well a physician practices medicine.”
“Why do you want that
information, then?” Greenwood pressed, before answering his own
question: “To see how successful your marketing techniques are.”
Greenwood
then observed that, in a recent case involving a Pennsylvania doctor,
Richard Paolino, who was wantonly overprescribing OxyContin, a local
pharmacist had alerted the authorities. “He looked at this data and he
said, ‘Holy God, there is some guy in Bensalem called Paolino, and he’s
writing prescriptions out the wazoo,’ ” Greenwood said. “Now, he had
that data and he blew the whistle. And you had that data. What did you do?”
Purdue
had not alerted the authorities. Clinicians like Paolino were breaking
the law—he was sentenced to a minimum of thirty years in prison. But
overprescribing generated tremendous revenue for the company. According
to four people I spoke with, at Purdue such prescribers were given a
name that Las Vegas casinos reserve for their most prized gamblers:
whales.
In
July, 2001, Richard Blumenthal, who was then the attorney general of
Connecticut, wrote to Richard Sackler. “I have been increasingly
dismayed and alarmed about the problems and escalating abuse of
OxyContin,” he began, citing overdose deaths, addiction, pharmacy
robberies, and “the astonishing growth in state funding” that was being
used to pay for OxyContin prescriptions through Medicaid and Medicare.
Blumenthal acknowledged that other prescription drugs were also abused.
“But OxyContin is different,” he wrote. “It is more powerful, more
addictive, more widely sold, more illicitly available, and more
publicized.” He urged Purdue to “overhaul and reform” its marketing of
OxyContin.
The Sacklers disregarded his recommendation, and so in
2004 Blumenthal filed a complaint against Purdue, on behalf of the State
of Connecticut. It cited data indicating that a fifth of OxyContin
prescriptions were now for dosing intervals shorter than twelve hours.
In fact, Blumenthal obtained Purdue records indicating that company
officials knew by 1998 that prescriptions for eight-hour intervals were
becoming more and more frequent. In one document, a Purdue employee
called the numbers “very scary.”
Such alarm over off-label dosing
may have been prompted less by concern about public health than by
considerations of profit. If OxyContin was being widely prescribed at
intervals of fewer than twelve hours, the company might lose its “two
pills a day” marketplace advantage against cheaper alternatives, like
generic morphine, and insurers could start refusing to cover the costs.
As early as 1997, some benefit plans had begun citing abuse of OxyContin
as an excuse not to pay. In a 1997 e-mail, Richard Sackler urged
colleagues to counter this resistance, warning that, for insurance
companies, “ ‘addiction’ may be a convenient way to just say ‘NO.’ ”
Purdue has been sued thousands of times over OxyContin since its
release. (Steven May, the sales rep, initiated a whistle-blower suit
years after leaving the company; it was dismissed, on procedural
grounds.) In 2002, Howard Udell said that the firm would defend itself
“to the hilt.” The next year, a New York trial lawyer named Paul Hanly
assembled a lawsuit, signing up five thousand patients who said that
they’d become addicted to OxyContin after receiving a doctor’s
prescription. In discovery, Hanly obtained thousands of documents. “They
demonstrated that this company had set out to perpetrate a fraud on the
entire medical community,” he told me. “These pronouncements about how
safe the drug was emanated from the marketing department, not the
scientific department. It was pretty shocking. They just made this stuff
up.”
In 2006, Purdue
settled with Hanly’s clients, for seventy-five million dollars. Shortly
afterward, the company pleaded guilty, in a case brought by federal
prosecutors in Virginia, to criminal charges of misbranding, and
acknowledged that Purdue had marketed OxyContin “with the intent to
defraud or mislead.” (Rudolph Giuliani had tried, on Purdue’s behalf, to
get the lead prosecutor to scuttle the case.) Michael Friedman, the
executive vice-president, pleaded guilty to a criminal misdemeanor, as
did Howard Udell and the company’s chief medical officer, Paul
Goldenheim.
Marianne
Perez attended the sentencing, in Virginia. “I was on cloud nine,” she
recalled. She had been working with the prosecution, and doing
everything she could to inform the public about the dangers of
OxyContin. Before the sentence was handed down, Perez delivered a
victim-impact statement. “I want to know why the Sackler brothers have
not been held accountable,” she said. (Richard Sackler, despite his
leadership role at Purdue, had not been charged.)
During a break
in the proceedings, Perez looked over at Friedman, Goldenheim, and
Udell, and told herself, “I could reach over, at ninety-eight pounds,
and smack one of them.” This time, she restrained herself. Instead, she
told them, “You are sheer evil. You are bastards.” The executives
reddened, but said nothing. They all received probation, and were
ordered, collectively, to pay nearly thirty-five million dollars in
fines. Purdue agreed to pay an additional six hundred million. Given the
billions of dollars that the Sacklers and Purdue had reaped from
OxyContin, some observers felt that the company had got off easy. Arlen
Specter, the Republican senator from Pennsylvania, remarked that such
fines amounted to “expensive licenses for criminal misconduct.”
Arthur Sackler wrote a regular column for the Medical Tribune,
and one of his fixations was the unethical behavior of tobacco
companies. In 1979, he critiqued the “weasel-worded warning” on
cigarette packages as insufficient, arguing that the “hazard to health
should be more specific.” He also condemned newspapers and magazines for
accepting “misleading” advertising about cigarettes, and contended that
the publishers must “square with their own consciences their
contribution to our national mortality.”
In 1998, the tobacco
industry, which had been sued by dozens of states, entered into the
largest civil-litigation settlement in history, agreeing to pay two
hundred and forty-six billion dollars. Tobacco and opioids are different
in significant ways. The F.D.A. approved OxyContin as a medicine, and,
whereas tobacco can kill you even when used as directed, Purdue would
argue that this isn’t the case with OxyContin. Mike Moore, who, as
Mississippi’s attorney general, played a key role in the tobacco
litigation, noted another difference: the tobacco companies had more
money to spare than Purdue does. “To resolve the opioid problem, you’re
going to need billions,” he said. “Treatment alone could be fifty
billion dollars or more. And you need prevention and education programs
on top of that.”
Moore is now working with Paul Hanly and other
attorneys to bring a fresh wave of lawsuits against Purdue and other
pharmaceutical companies. Ten states have filed suits, and private
attorneys are working in partnership with dozens of cities and counties
to bring others. Many public officials are furious at the makers of
powerful painkillers. Prescriptions are expensive, and taxpayers often
foot the bill, through programs like Medicaid. Then, as the ruinous
consequences of opioid addiction take hold, the public must pay
again—this time for emergency services, addiction treatment, and the
like. Moore feels that the Sackler family, as the initial author and a
prime beneficiary of the epidemic, should be publicly shamed. “I don’t
call it Purdue. I call it the Sackler Company,” he said. “They are the
main culprit. They duped the F.D.A., saying it lasted twelve hours. They
lied about the addictive properties. And they did all this to grow the
opioid market, to make it O.K. to jump in the water. Then some of these
other companies, they saw that the water was warm, and they said, ‘O.K.,
we can jump in, too.’ ” There may be significant legal distinctions
between a tobacco company and an opioid producer, but to Moore the
ethical parallel is unmistakable: “They’re both profiting by killing
people.”
One day in August, 2015, a plane landed in Louisville,
Kentucky, and Richard Sackler stepped out, surrounded by attorneys.
Eight years earlier, the State of Kentucky had sued Purdue, charging the
company with deceptive marketing. Greg Stumbo, the state attorney
general at the time, initiated the suit; the son of a cousin of his had
fatally overdosed on OxyContin. Purdue fought the suit with
its customary rigor, pushing to move the proceedings elsewhere, on the
ground that the company could not get a fair trial in Pike County,
Kentucky—the rural stretch of coal country where the state intended to
try the case. In support of this motion, the company commissioned a
demographic study of Pike County and submitted it to the court, as an
illustration of potential bias in the jury pool. The report was
revealing in ways that Purdue may not have intended: according to the
filing, twenty-nine per cent of the county’s residents said that they or
their family members knew someone who had died from using OxyContin.
Seven out of ten respondents described OxyContin’s effect on their
community as “devastating.”
A judge ruled that Purdue could not shift the venue for the trial, and
so Richard Sackler flew to Louisville. He gave a deposition at a law
firm. Four lawyers questioned him about his role in the development and
the marketing of OxyContin. Tyler Thompson, the lead attorney, told me
that Sackler’s demeanor during the session reminded him of Jeremy
Irons’s portrayal of Claus von Bülow, the aristocrat accused of
murdering his wife, in the 1990 bio-pic “Reversal of Fortune.”
“A smirk and a so-what attitude—an absolute lack of remorse,” Thompson
said. “It reminded me of these mining companies that come in here and do
mountaintop removal, and leave a mess and just move on: ‘It’s not my
back yard, so I don’t care.’ ” Mitchel Denham, a former litigator in the
Kentucky attorney general’s office, also attended the deposition. “It
was surreal,” he recalled. “We were face to face with the guy whose
company had helped to create the opioid epidemic.” Denham told me that,
in preparing for trial, he discovered a photograph of the 1997 Pikeville
High School football team. “Nearly half the players had died of
overdoses, or were addicted,” he said. “It was going to be a pretty good
visual.”
But Denham never
presented the photograph to a jury, because before the case could go to
trial Purdue settled, for twenty-four million dollars. This was a coup
for the Sacklers. The settlement was more than Purdue’s original
offer—half a million dollars—but still totally incommensurate with Pike
County’s needs; Purdue admitted no liability; and, in settling, the
company sealed from public view both Richard Sackler’s deposition and
internal documents obtained through discovery. Purdue has sometimes
claimed to have never “lost a case” related to OxyContin, but it’s more
accurate to say that the company has never allowed a case to go to
trial, often settling rather than litigating the culpability of the
company—and the Sacklers—in open court. “That’s the main reason these
folks don’t go to trial,” Denham said. “Because all these documents
could end up in the public record.” The Kentucky prosecutors were
required to destroy millions of documents, or return them to Purdue. The
medical-news Web site STAT subsequently sued to unseal Richard
Sackler’s deposition. A state judge ruled in its favor, but Purdue
appealed. I spent several months trying to obtain a copy of the
deposition, but, because it remains under a protective order while
Purdue appeals the matter, no lawyer would share it with me. Mike Moore
said, “The idea that they’re fighting so hard to keep this deposition
hidden should tell you something.”
Richard Sackler stepped down as
Purdue’s president in 2003, but stayed on as co-chairman of the
company’s board. After spending several years as an adjunct professor of
genetics at Rockefeller University, he moved to Austin, Texas, in 2013.
He lives in a modern hilltop mansion on the outskirts of the city, in
an area favored by tech entrepreneurs. According to tax disclosures from
his personal foundation, he has continued giving money to Yale, but his
largest donation in 2015 was a hundred-thousand-dollar gift to a
neoconservative think tank, the Foundation for Defense of Democracies.
Through a representative, Sackler declined to speak with me. I contacted
a dozen other members of the Sackler family, but none of them would
answer questions about OxyContin. Jo Sheldon, a London-based media
adviser, called me, and said that she works with some of the Sacklers.
(She would not identify which ones.) When I told her that I had
questions for the Sacklers, she said that my inquiries would be better
directed to Purdue. She said of the Sacklers, “Some of them are still
quite involved in Purdue, but some have absolutely nothing to do with
it,” apart from depositing checks.
Given the sometimes fractious
nature of the Sackler family, it was striking that they were united in
their silence on the subject of OxyContin. These were urbane,
expensively educated, presumably well-informed people. Could they
conceivably be unaware of the accumulated evidence about the tainted
origins of their fortune? Did they simply put it out of mind? “Greed can
get people to rationalize pretty bad behavior,” Andrew Kolodny had told
me. Someone who knows Mortimer, Jr., socially told me, “I think for
him, most of the time, he’s just saying, ‘Wow, we’re really rich. It’s
fucking cool. I don’t really want to think that much about the other
side of things.’ ”
Paul
Hanly, the lawyer, said that the Sacklers’ steadfast refusal to address
the legacy of OxyContin may just be a legal tactic—and a shrewd one.
“The more interviews you give, the more targets you create for lawyers
like me, and for government
investigators,” he said. I wondered whether philanthropy might
represent, for at least some of the Sacklers, a form of atonement. But,
when you consider the breadth of the family’s donations, one field is
conspicuously lacking: addiction treatment, or any other measures that
might serve to counter the opioid epidemic.
In
August, 2010, Purdue quietly replaced OxyContin with a drug that was
subtly different. The company had been granted patents for a
reformulated version of OxyContin. If you crushed these new pills, they
became not a fine, dissolvable powder but an unwieldy gummy substance.
Purdue had received F.D.A. approval for the reformulation, in part, by
touting the ostensible safety of the new product. The F.D.A. had
approved a label, the first of its kind, that included a claim about the
drug’s “abuse deterrent” properties.
In an interview, Craig
Landau, Purdue’s C.E.O., told me, “A very large proportion of Purdue’s
R. & D. efforts post-2001 was dedicated toward addressing the
specific vulnerability of the original OxyContin product.” To a casual
observer, it might have seemed that the makers of OxyContin, after years
of obstructing efforts to curb the disastrous impacts of their
painkiller, had finally seen the error of their ways. But Purdue was
almost certainly motivated by another consideration: it needed to block
competition from generic drugs. Arthur Sackler had often used the pages
of the Medical Tribune to criticize generics. In 1985, the
paper had published a story, “Schizophrenics ‘Wild’ on Weak Generic,”
describing how “all hell broke loose” at a veterans’ hospital after the
psychiatric unit switched from a brand-name antipsychotic to a generic. (According to the Times,
the F.D.A. investigated and found that the story was bogus, because
“the generic had been introduced six months before the purported
problems began.”) I spoke with a leading patent lawyer who frequently
represents manufacturers of generic drugs, and she said that companies
often make a minor tweak to a branded product shortly before the patent
expires, in order to obtain a new patent and reset the clock on their
exclusive right to produce the drug. The patent for the original
OxyContin was set to expire in 2013.
Purdue had long
denied that the original OxyContin was especially prone to abuse. But,
upon receiving its patents for the reformulated drug, the company filed
papers with the F.D.A., asking the agency to refuse to accept generic
versions of the original formulation—because they were unsafe. The
F.D.A., ever obliging, agreed, blocking any low-cost generic competition
for Purdue. For more than a year, Purdue continued to sell the original
formulation of OxyContin in Canada. According to a recent study,
OxyContin sales in Windsor, Ontario—just across the border from
Detroit—suddenly quadrupled, a clear indication that the pills were
being purchased for the U.S. black market. Through I.M.S. tracking data,
Purdue would have been able to monitor the Canadian surge, and to
deduce the reason for it. (The company acknowledges that it was aware of
the spike in sales, and maintains that it alerted authorities, but will
not say when it did so.)
By the time Purdue reformulated
OxyContin, the country was in the middle of a full-blown epidemic.
Andrew Kolodny, the addiction specialist, told me that many older people
remain addicted to the reformulated OxyContin, and continue to obtain
the drug through prescriptions. These people purchase the drug legally,
and swallow the pills whole, as instructed. “That’s Purdue’s market
now,” Kolodny said. Younger people, who can less readily secure
prescriptions for pain—and for whom OxyContin may be too expensive—have
increasingly turned to black-market substitutes, including heroin. As
Sam Quinones details in his 2015 book, “Dreamland: The True Tale of America’s Opiate Epidemic,”
heroin dealers from Mexico fanned out across the U.S. to supply a
burgeoning market of people who had been primed by pill addiction. This
is one dreadful paradox of the history of OxyContin: the original
formulation created a generation addicted to pills; the reformulation,
by forcing younger users off the drug, helped create a generation
addicted to heroin. A recent paper by a team of economists, citing a
dramatic uptick in heroin overdoses since 2010, is titled “How the Reformulation of OxyContin Ignited the Heroin Epidemic.”
A survey of two hundred and forty-four people who entered treatment for
OxyContin abuse after the reformulation found that a third had switched
to other drugs. Seventy per cent of that group had turned to heroin.
Perhaps
the most surprising aspect of Quinones’s investigation is the
similarities he finds between the tactics of the unassuming,
business-minded Mexican heroin peddlers, the so-called Xalisco boys, and
the slick corporate sales force of Purdue. When the Xalisco boys
arrived in a new town, they identified their market by seeking out the
local methadone clinic. Purdue, using I.M.S. data, similarly targeted
populations that were susceptible to its product. Mitchel Denham, the
Kentucky lawyer, told me that Purdue pinpointed “communities where there
is a lot of poverty and a lack of education and opportunity,” adding,
“They were looking at numbers that showed these people have work-related
injuries, they go to the doctor more often, they get treatment for
pain.” The Xalisco boys offered potential customers free samples of
their product. So did Purdue. When it first introduced OxyContin, the
company created a program that encouraged doctors to issue coupons for a
free initial prescription. By the time Purdue discontinued the program,
four years later, thirty-four thousand coupons had been redeemed.
Purdue
Pharma now acknowledges that there is an opioid crisis, but maintains
that it has taken every available step to address it, from sponsoring
“prescription monitoring” programs in some states to underwriting
drug-abuse education. Craig Landau, the C.E.O., told me, “If the Holy
Grail is a pain medicine that is safe and effective for patients with
severe pain but carries no abuse risk, we haven’t found it yet.” He
added that the company has been trying to develop “non-opioid pain
products.” Purdue likes to emphasize that there are many other powerful
painkillers, and that OxyContin never had more than two per cent of the
market for opioids. This is true in terms of the number of
prescriptions. But most painkillers are prescribed for very short
periods—following surgery, for instance—and in relatively small doses,
whereas OxyContin’s sales have been driven by long-term, high-dose
prescriptions. If one measured market share by the actual volume of
narcotics administered, OxyContin’s would be considerably higher. Some
doctors I spoke with estimated that it could be as high as thirty per
cent.
The United States accounts for roughly a third of the global market for
opioid painkillers. But, as politicians and journalists have raised
alarms over the addiction crisis, many American doctors have grown
leery, again, of prescribing these drugs. In a statement, Purdue
acknowledged that even patients “who take OxyContin in accordance with
its F.D.A.-approved labeling instructions will likely develop physical
dependence.” The company maintains that physical dependence is different
from addiction, but Jane Ballantyne, the president of Physicians for
Responsible Opioid Prescribing, said that, for patients, this can be a
meaningless distinction: if they find themselves unable to stop taking a
drug, for fear of crippling withdrawal, “at a certain point that might
as well be addiction.” The drugstore chain CVS, which has been accused
of profiteering from opioids, recently announced that it plans to limit
prescriptions for powerful doses to one week’s worth, a change that
could have a major impact on the abuse of these drugs. It may also be
that OxyContin has achieved market saturation. In recent years, American
clinicians have issued about a quarter of a billion opioid
prescriptions annually. Last year, in Ohio, a state particularly hard
hit by the epidemic, 2.3 million residents—roughly one in five people in
the state—received a prescription for opioids. In 2012, the Milwaukee Journal Sentinelpublished a story
about pain patients who had offered testimonials about the wonders of
OxyContin in Purdue promotional videos. Johnny Sullivan, the
construction worker who had talked about OxyContin easing his back pain,
became addicted to the drug. In 2008, while driving home from a hunting
trip, he apparently blacked out; he flipped his truck, and died
instantly. In a Purdue brochure, Sullivan is quoted as saying that
OxyContin pills “don’t put me in a stupor or make me groggy.”
David Juurlink, the Toronto doctor, told me that opioids are
problematic even for users who don’t succumb to addiction. “Opioids
really do afford pain relief—initially,” he said. “But that relief tends
to diminish over time. That’s, in part, why people increase the dose.
They are chasing pain relief from a drug that has failed. I see all
these people who are convinced they are one of the ‘legitimate’ pain
patients. They’re on a massive dose of opioids, and they’re telling me
they need this medication, which is clearly doing them harm. For many of them, the primary benefit of therapy, at this point, is not going into withdrawal.”
Even
Russell Portenoy, the Purdue-funded doctor who advocated for wider
long-term use of opioids, has reassessed his views. “Did I teach about
pain management, specifically about opioid therapy, in a way that
reflects misinformation?” he said to the Wall Street Journal
in 2012. “I guess I did.” (In a statement, Portenoy told me that he has
“refocussed” his approach to pain management, adding, “No funder has
had any undue influence over my thinking.”)
In his defense,
Portenoy has pointed out that, two decades ago, doctors did not know
what they know now about opioids and addiction. The Sackler family and
Purdue Pharma could have taken responsibility in a similar spirit:
apologizing for their role in unleashing a national catastrophe while
noting that, during the nineties, they had relied on a series of
mistaken assumptions about the safety of OxyContin. But Purdue has
continued to fight aggressively against any measures that might limit
the distribution of OxyContin, in a way that calls to mind the gun
lobby’s resistance to firearm regulations. Confronted with the prospect
of modest, commonsense measures that might in any way impinge on the
prescribing of painkillers, Purdue and its various allies have responded
with alarm, suggesting that such steps will deny law-abiding pain
patients access to medicine they desperately need. Mark Sullivan, a
psychiatrist at the University of Washington, distilled the argument of
Purdue: “Our product isn’t dangerous—it’s people who are dangerous.”
Last
year, the C.D.C., which formally declared an opioid epidemic in 2011,
introduced the first set of guidelines to help reduce the prescribing of
strong painkillers like OxyContin. “Opioids should not be considered
first-line or routine therapy for chronic pain,” the guidelines said,
recommending that doctors first consider “non-pharmacologic” approaches,
such as physical therapy, and “non-opioid pharmacologic” treatments.
Purdue
and other pharmaceutical companies have long funded ostensibly neutral
nonprofit groups that advocate for pain patients. The C.D.C. guidelines
were nonbinding, yet many of these
organizations fought to prevent the agency from releasing them. This
kind of obstruction is typical at both the state and the federal level. A
recent series by the Associated Press and the Center for Public
Integrity revealed that, after Purdue made its guilty plea, in 2007, it
assembled an army of lobbyists to fight any legislative actions that
might encroach on its business. Between 2006 and 2015, Purdue and other
painkiller producers, along with their associated nonprofits, spent
nearly nine hundred million dollars on lobbying and political
contributions—eight times what the gun lobby spent during that period.
Since
Purdue made it more difficult to grind OxyContin pills, prescriptions
have reportedly plummeted by forty per cent. This suggests that nearly
half of the original drug’s consumers may have been crushing it to get
high. As David Juurlink pointed out to me, it is a misnomer to call the
reformulation an “abuse deterrent.” It can still be abused—and is,
widely, by people who become addicted by swallowing the pills, just as
the bottle instructs. But Purdue, facing a shrinking market and rising
opprobrium, has not given up the search for new users. In August, 2015,
over objections from critics, the company received F.D.A. approval to
market OxyContin to children as young as eleven.
Forbesestimates
that the Sacklers continue to receive some seven hundred million
dollars a year from the family companies, and, as the Sacklers are
surely aware, the real future of OxyContin may be global. Many big
companies, once their sales plateau in America, look abroad. After
introducing OxyContin in the U.S., Purdue moved into Canada and England.
At the University of Toronto, the company sponsored a class on pain
management for medical and dental students. The instructor was a member
of Purdue’s speakers’ bureau. Students received a complimentary
textbook, produced by Purdue, that described oxycodone as a “moderate”
opioid. The course was discontinued after students and doctors
criticized it; one of the critics was Rick Glazier, a physician at the
university, whose son, Daniel, had fatally overdosed on OxyContin in
2009.
As OxyContin spread outside the U.S., the pattern of
dysfunction repeated itself: to map the geographic distribution of the
drug was also to map a rash of addiction, abuse, and death. But the
Sackler family has only increased its efforts abroad, and is now pushing
the drug, through a Purdue-related company called Mundipharma, into
Asia, Latin America, and the Middle East. Part of Purdue’s strategy from
the beginning has been to create a market for OxyContin—to instill a
perceived need by making bold claims about the existence of large
numbers of people suffering from untreated chronic pain. As Purdue moves
into countries like China and Brazil, where opioids may still retain
the kind of stigma that the company so assiduously broke down in the
United States, its marketing approach has not changed. According to a Los Angeles Times report
from 2016—well after the Sacklers’ playbook for OxyContin had been
repudiated by the medical establishment as possibly the main driver of
the opioid epidemic—Mundipharma commissioned studies showing that
millions of people in these countries suffered from chronic pain. The
company has organized junkets, and paid doctors to give presentations
extolling OxyContin’s virtues. In fact, certain doctors who are
currently flogging OxyContin abroad—“pain ambassadors,” they are
called—used to be on Purdue’s payroll as advocates for the drug in the
U.S.
The Times
report described Joseph Pergolizzi, Jr.—a Florida doctor who runs a
pain-management clinic and hawks a pain-relieving cream of his own
invention on cable TV—giving paid talks in places like Brazil about the
merits of OxyContin. In Mexico, Mundipharma has asserted that
twenty-eight million people—a quarter of the population—suffer from
chronic pain. In China, the company has distributed cartoon videos about
using opioids for pain relief; other promotional literature cites the
erroneous claim that rates of addiction are negligible. In a 2014
interview, Raman Singh, a Mundipharma executive, said, “Every single
patient that is in emerging markets should have access to our
medicines.” The term “opiophobia” has largely fallen into disuse in
America, for obvious reasons. Mundipharma executives still use it
abroad.
“It’s a parallel to what the tobacco industry did,” Mike
Moore told me. “They got caught in America, they saw their market share
decline, so they export it to places with even fewer regulations than we
have.” He added, “You know what’s going to happen. You’re going to see
lots and lots of death.” In May, several members of Congress wrote to
the World Health Organization, urging it to help stop the spread of
OxyContin, and mentioning the Sackler family by name. “The international
health community has a rare opportunity to see the future,” they wrote.
“Do not allow Purdue to walk away from the tragedy they have inflicted
on countless American families simply to find new markets and new
victims elsewhere.” David Kessler, the former F.D.A. commissioner,
believes that the destigmatization of opioids in the U.S. represents one
of the “great mistakes” of modern medicine. When I asked for his
thoughts on Mundipharma’s efforts to market OxyContin abroad, he said,
“It gives me a sick feeling. It makes me ill.”
Earlier this year, Peter Salovey, the president of Yale, announced that the university will rename a residential college that was named for John C. Calhoun, because Calhoun’s “legacy as a white supremacist and a national leader who passionately promoted slavery
as a ‘positive good’ fundamentally conflicts with Yale’s mission and
values.” This move, which was not without its critics, was emblematic of
a broader trend to look back skeptically at individuals who were
venerated in earlier epochs, and ask how they should be judged by the
moral standards of today. At Oxford, a Rhodes Scholar from South Africa
recently led a campaign to take down a statue of Cecil Rhodes.
One
great fortune—and reputation—that has evaded such scrutiny is that of
the Sacklers, a family whose dubious business practices are not an
artifact of previous centuries but an ongoing reality. If present
statistics are any indication, in the time it likely took you to read
this article six Americans have fatally overdosed on opioids. Yet Yale
appears to be in no hurry to rename its Raymond and Beverly Sackler
Institute for Biological, Physical and Engineering Sciences, or its
Richard Sackler and Jonathan Sackler Professorship of Internal Medicine.
Perhaps it’s because the Sacklers, unlike the Calhoun family, still
have a fortune to give away.
“It’s amazing how they are left out
of the debate about causation, but also about solutions,” Allen Frances,
the Duke psychiatrist, said of the Sacklers. “A truly philanthropic
family, looking at the last twenty years, would say, ‘You know, there’s
several million Americans who are addicted, directly or indirectly,
because of us.’ Real philanthropy would be to contribute money to taking
care of them. At this point, adding their name to a building—it rings
hollow. It’s not philanthropy. It’s just a glorification of the Sackler
family.” According to the American Society of Addiction Medicine, more
than two and a half million Americans have an opioid-use disorder.
Frances continued, “If the Sacklers wanted to clear their name, they
could take a very substantial fraction of that fortune and create a
mechanism for providing free treatment for everyone who’s become
addicted.” Alfred Nobel, the inventor of dynamite, created the Nobel
Peace Prize. In recent years, several philanthropic organizations run by
the descendants of John D. Rockefeller have devoted resources to
addressing climate change and critiquing the environmental record of the
oil company he founded, now called ExxonMobil. Last year, Valerie
Rockefeller Wayne told CBS, “Because the source of the family wealth is fossil fuels, we feel an enormous moral responsibility.”
Mike Moore, the former Mississippi attorney general, believes that
the Sacklers will feel no pressure to emulate this gesture until more of
the public becomes aware that their fortune is derived from the opioid
crisis. Moore recalled his initial settlement conference with
tobacco-company C.E.O.s: “We asked them, ‘What do you want?’ And they
said, ‘We want to be able to go to cocktail parties and not have people
come up and ask us why we’re killing people.’ That’s an exact quote.”
Moore is puzzled that museums and universities are able to continue
accepting money from the Sacklers without questions or controversy. He
wondered, “What would happen if some of these foundations, medical
schools, and hospitals started to say, ‘How many babies have become
addicted to opioids?’ ” An addicted baby is now born every half hour. In
places like Huntington, West Virginia, ten per cent of newborns are
dependent on opioids. A district attorney in eastern Tennessee recently
filed a lawsuit against Purdue, and other companies, on behalf of “Baby
Doe”—an infant addict.
Purdue executives won’t be able to settle
every case against them, Moore believes. “There’s going to be a jury
somewhere, someplace, that’s going to hit them with the largest judgment
in the nation’s history,” he said. Paul Hanly noted that, in the face
of a crippling judgment, Purdue may have to declare bankruptcy. “But I’m
certainly not going to walk away if they do,” he said. “At that point, I
would start looking closely at individual liability on the part of the
Sacklers.”
Robin
Hogen, the former Purdue communications executive, said, “I don’t want
to be portrayed as an apologist for what is clearly a public-health
crisis. But I wanted to make sure you spoke to someone who had very high
regard for the Sackler family. The Sacklers were first class in
everything they did.” I asked him what he would say to the doctors and
the public-health officials who believe that the heirs of Raymond and
Mortimer Sackler bear some moral responsibility for the epidemic. “I’m
not a doctor,” Hogen demurred. “I really can’t comment.”
The
Sacklers have always excelled at the confidence game of marketing, and
it struck me that the greatest trick they ever pulled was to write the
family out of the history of the family business. I was reminded of
Arthur Sackler’s admonition that you should endeavor to leave the world a
better place than it was when you came into it, and I wondered about
the moral arithmetic of the Sacklers’ deeds. But the family, through a
Purdue representative, declined to comment.
I
recently went to Amagansett, on Long Island, to meet a man I’ll call
Jeff. At a restaurant, he told me about his struggles with addiction. A
decade ago, when he was a teen-ager, he started abusing opioids. They
were “everywhere,” he recalled. He particularly liked OxyContin, for the
“clean high” it provided. After sucking the pill’s red coating off, he
crushed the rest with the edge of a cigarette lighter, then snorted it.
He didn’t inject it. “When I was growing up, I always told myself, ‘I’ll never stick a needle in my arm,’ ” he said.
In
a soft, unflinching tone, Jeff recounted the next decade of his life:
he kept abusing painkillers, met a woman, fell in love, and introduced
her to opioids. One day, his dealer was out of pills and said, “I’ll
sell you a bag of heroin for twenty bucks.” Jeff was reluctant, but when
withdrawal set in he acquiesced. At first, he and his girlfriend
snorted heroin. “But you build up a tolerance, just like with the
pills,” he said, and eventually they started injecting it. They were
high when they got married. Jeff’s wife gave birth to a boy, who was
addicted to opioids. “The doctors weaned him off with droplets of
morphine,” he said.
After a long stretch in rehab, Jeff has been
sober for more than a year. His baby is healthy, and his wife is clean,
too. Looking back, he said, he feels that an impulsive youthful decision
to snort pills set him on a path from which he could not deviate. “It
was all about the drug,” he said. “I just created a hurricane of
destruction.”
We left the restaurant and strolled along a leafy
side street flanked by grand houses. During the worst years of his
addiction, Jeff worked as a tradesman in the area. I had asked him to
show me a property that he had serviced, and we stopped outside a
sprawling estate that was mostly hidden behind dense shrubbery. It was
the home of Mortimer Sackler, Jr. Jeff, who knew about the family,
appreciated the irony. “I couldn’t tell you how many times I was on that
property, sitting in a work truck, snorting a pill,” he said.
We
reached an ornamental wooden gate, beyond which was a yard dominated by a
stately weeping willow. As I was admiring the tree, Jeff said that, for
the people who maintained the grounds, it was “a pain in the ass.”
Whenever the wind picks up, he explained, branches break and scatter all
over the lawn. “But the place has to be flawless,” he said. “There
can’t be a leaf on the ground.” So a crew comes by regularly, to clear
away the mess. ♦
This article appears in the print edition of the October 30, 2017, issue, with the headline “Empire of Pain.”
Patrick Radden Keefe, a staff writer, has been contributing to The New Yorker since 2006.
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