Recent Reading: Empire of Pain

 

I finished Patrick Radden Keefe's book Empire of Pain a few weeks ago. I noted a number of passages and thought I would share them here. I was motivated to do this because the book is a library book and is coming due soon.

Radden Keefe started with an article that he published in the New Yorker in 2017. The book, with more than 500 pages, obviously, goes into greater depth than the article was able to. The basic idea of the book is an attempt to give deep answers to two questions:

1. Who are the Sacklers? 
2. And what did their company, Purdue Pharma do in relation to opioids?
   

The fact that Radden Keefe takes over 500 pages to answer these two questions lets you know that the answer is both complicated and devastating.

While other pharmaceutical companies have a diversified portfolio, this was not true of Purdue Pharma.

Purdue's leadership was so single-minded in extending the life of OxyContin, in fact, that it sometimes seemed to this executive as if the company wasn't a pharmaceutical company at all but "an intellectual property law firm that happened to have some R&D and a marketing arm" (p 308).

The Sackler family certainly had well paid people to give them advice. However,

One unadvertised hazard in the life of a plutocrat is that the people around  you can be prone to yes-man sycophancy. In theory, you should be able to avail yourself to state-of-the-art counsel. But instead, you often get lousy advice, because your courtiers are careful to tell you only what they think you want to hear. The danger, whether you are a billionaire executive or the president of the United States, is that you end up compounding this problem yourself, by marginalizing any dissenting voices and creating a bubble in which loyalty is rewarded above all else. The Sacklers took pride in being loyal to those who showed great loyalty to them. If you stood by the family, they would take care of you. But it was an unwritten corollary in the company that anyone who quit to take another job would be blacklisted from returning, for life. Consequently, the Sacklers remained insulated by a retinue of stalwarts who both shared and reinforced the family's view that the company was being unfairly maligned and had done nothing wrong. Among the members of this faction, one former executive recalled, "Nobody wags outraged about what the L.A. Times uncovered. The reaction was silence" (p. 342).

I liked this observation on whether or not we really need OxyContin

"as a civilization we somehow managed to survive for 50,000 years without OxyContin," one doctor, Lewis Nelson, who advised the agency on the guidelines, said. "I think we will continue to survive."

Here is an idea I had not thought about before I read this book, are doctors taught about the risks and benefits of having their patients go off opioids?

But there was also some validity to the concern that in the face of the new guidelines and enhanced scrutiny of prescribers by the authorities, physicians might swing too hard in the other direction, abruptly cutting off patients who had come to depend on these drugs. That, too, could have major negative consequences for public health, driving patients onto the black market, or neglecting the legitimated suffering of people who were living with chronic pain. It was an excruciatingly delicate problem, from both a policy and medical point of view -- and it was compounded by the fact that most physicians were not trained in how to gradually taper a patient off opioids. The industry had taught doctors how to get people on these drugs, but not how to get them off (p. 348).

The Sackler family certainly benefited from the fact that opioid addiction is a complex phenomenon.

It was not as though the Sacklers had not been written about before Barry Meier and Sam Quinones had detailed the history of the family and the company in their books. But until then, the Sacklers had tended to be presented as one strand in a complex narrative involving OxyContin, Purdue, pain doctors, patients, and the burgeoning opioid crisis. This was no surprise, and no shortcoming on the part of the prior reporting; because the Sacklers were so secretive, and Purdue was a privately held company, it had been difficult, up to that point, to tell a story in which the culpability of the family was from and center (p. 354).

Perhaps one of the biggest lessons to be learned from Radden Keefe's reporting is that because the Sacklers were so rich and so powerful very little was done to investigate them and their company.

The opioid crisis is, among other things, a parable about the awesome capability of private industry to subvert public institutions. Just as the FDA was compromised and Congress was neutralized or outright co-opted with generous donations and some federal prosecutors were undermined with a back-channel appeal in Washington while others were mollified with the promise of a corporate job, just as state legislators and the CDC were hindered and sabotaged when they tried to curb opioid prescribing, the DEA was not immune to these pressures and proceeded to soften its position under a steady barrage of industry encouragement. Between 1994 and 2015, the quota of oxycodone that the DEA permitted to be legally manufactured was raised thirty-six times. A subsequent report by the inspector general of the Justice Department criticized the DEA for being "slow to respond to the dramatic increase in opioid abuse" (p. 364).

By the time the broader public understood that the name Sackler and opioids were connected the public was understandably outraged:

It was a measure of just how intense the opprobrium had become that a New Jersey man, who happened to be named David Sackler, initiated a lawsuit of his own against a number of media outlets that had used a photograph of him, instead of the other David Sackler, in stories about the family. Being taken "for the wrong David Sackler had undermined his reputation," the lawsuit contended, mentioning that this David Sackler had been reduced to adopting a pseudonym to get a table in a restaurant. Not to be left out, Purdue University, in West Lafayette, Indiana, issued a press release clarifying that it "has never been affiliated in any way with Purdue Pharma" (p. 390).

Perhaps my my favorite moment when the Sackler family went from being an unknown family who happened to donate to galleries and medical schools to a family believed to be responsible, in large part for the opioid crisis, was on an episode of HBO's show Last Week Tonight. 

Do yourself a favor and click on the link below to see the videos; they are worth your time.

John Oliver, of the satirical news program Last Week Tonight, also aired a segment on the family. The long-standing invisibility of Sacklers "feels deliberate," Oliver mused. He pointed out that Richard Sackler never gave interviews. But the litigation was providing "glimpses of the depths of Richard's involvement." Oliver mentioned Richard's leaked Kentucky deposition, and he articulated a subtle point: because only the transcript had leaked, and not the video, it was difficult to do much with the deposition on the nightly news. How do you illustrate words on a page?

The show devised a diabolically creative solution. Oliver enlisted a series of prominent actors to deliver dramatic renditions of Richard's deposition and correspondence. The actor Michael Keaton, with an indifferent scowl, reenacted the moment when Richard was sent an article saying that fifty-nine people from a single state had died from overdoses and responded, "This is not too bad." Bryan Cranston, who played the meth kingpin Walter White in Breaking Bad, delivered a rendition of Richard's speech at the OxyContin launch at the Wigwam. Michael K. Williams, who played Omar Little in The Wire, offered a third interpretation, his features twisted into a bloodless grimace. And a fourth actor, Richard Kind, did a comedic send-up of all the many times Sackler replied to questions about his company and his own conduct with the words "I don't know." Oliver told viewers that he had set up a website, sacklergallery.com, where they could watch more of these clips. He'd chosen the web address, he said, because "they love having their name on fucking galleries" (pgs. 390-391).