186 - The Opioid Crisis with Patrick Radden Keefe

KEYPOINTS

• 01

  The opioid crisis is a 25-year public health disaster with many players

  Patrick Radden Keefe, a New Yorker staff writer and author of Empire of Pain, says at least half a million Americans have died of opioid overdoses since the mid-to-late 1990s, and by some estimates more than 2 million have an opioid use disorder. The crisis moved from prescription pills to heroin, which Mexican cartels pushed after about 2010, and then to fentanyl. He focused on the Sacklers partly for the family drama, and partly because OxyContin was, in one insider's words, 'the tip of the spear'.

• 02

  Arthur Sackler pioneered modern pharmaceutical marketing

  The three Sackler brothers bought Purdue Frederick, a small 19th-century patent-medicine company once based on Christopher Street in Greenwich Village, in 1952. Arthur, the eldest, designed the advertising for Roche's Librium and then Valium, each the best-selling drug in history at the time, and was paid bonuses that rose with sales. Arthur died in 1987, before OxyContin existed, but Keefe devotes the first third of the book to him because Purdue later used the same methods.

• 03

  Purdue built OxyContin on its MS Contin playbook

  Purdue's controlled-release morphine for cancer pain, MS Contin, earned perhaps $300–400 million a year. As its patent neared expiry, the company applied the same coating to oxycodone and aimed it at the much larger market of non-cancer pain. Executives reasoned that they couldn't increase the number of people dying of cancer. Since the 1970s and 1980s, a school of physicians had argued that pain was undertreated and addiction risk overstated, and Purdue amplified that view.

• 04

  'Believed to reduce' abuse liability had no study behind it

  OxyContin's original 1996 package insert said the Contin delayed-absorption system 'is believed to reduce the abuse liability of the drug'. No study supported that claim. FDA medical officer Curtis Wright, who approved the drug largely on his own, later said Purdue officials wrote the line. In 1995 the company had sent him a webcam to communicate directly. About a year after approval, he took a job at Purdue for roughly three times his government salary.

• 05

  Purdue claimed ignorance of abuse, but its emails tell a different story

  Senior executives, including Richard Sackler, testified under oath that they knew of no problem until early 2000, when the US Attorney for Maine wrote to thousands of doctors. Keefe found internal emails from the late 1990s showing they knew early, and he says chief medical officer Paul Goldenheim's testimony to Congress was a bald-faced lie. In 1999, sales rep Steve May in Virginia was alarmed by one of his 'whales', the term reps used for very high prescribers.

• 06

  The black market helped pay Purdue's bills

  After the crush-resistant reformulation in 2010, sales of the 80 mg pill, the strength most popular on the black market, fell 25% nationwide. Keefe infers that until then about a quarter of 80 mg sales were going to people misusing the drug. From 1996, users had chewed, crushed or dissolved pills to snort or inject them, bypassing the time release that Purdue claimed made the drug safer. The label's warning not to crush the pills worked, Keefe says, as an inadvertent how-to.

• 07

  Two guilty pleas, and almost no individual accountability

  In 2007, Purdue pleaded guilty to federal charges and three executives pleaded to misdemeanours, but senior staff stayed and little changed. From about 2010 the company was 'back to committing crimes', and it pleaded guilty again in 2020 with no individuals even named. Over roughly a decade, the family took more than $10 billion out of the company. In 2019, facing thousands of lawsuits, Purdue filed for bankruptcy in White Plains. Judge Robert Drain approved a non-consensual release of third-party claims, and the family agreed to pay $4.5 billion over nine years from a fortune of about $11 billion, with most of the payments due at the end.

• 08

  Many institutions enabled the crisis

  Keefe describes bipartisan capture. HR 4709 was a three-page 'sleeper bill' that passed almost unopposed and, in Peter's words, tied the DEA's hands behind its back. Linden Barber went from being one of the DEA's most credible voices against unchecked distribution to lobbying for the distributors. Pain was promoted as the 'fifth vital sign', on posters in every hospital corner, measured on a subjective 1–10 scale that varies by person and culture.