Book Review: “Empire of Pain: the Secret History of the Sackler Dynasty” by Patrick Radden Keefe

 I came to read Empire of Pain not because of any strong interest in learning about the family and the pharmaceutical company which profited greatly and met their downfall from marketing a version of oxycodone, OxyContin, but because of my appreciation of the author. I had read another book by Patrick Radden Keefe, Say Nothing: A True Story of Murder and Memory in Northern Ireland, which I greatly liked and came to the conclusion that any book Mr. Keefe writes is probably worth reading. Both Empire of Pain and Say Nothing are nonfiction but read like novels. Keefe does a prodigious amount of research and then tells a captivating story. In addition to be entertained by the narratives, both books impart a great deal of information in a painless way. In reading Say Nothing, the reader will learn a great deal about sectarian conflict in Northern Ireland, and in reading Empire of Pain, the reader may come away somewhat horrified by pharmaceutical industry marketing practices and political influence.  

Empire of Pain recounts a multi-generational history of the Sacklers. The first part of the book devotes considerable attention to Arthur Sackler, who personally had nothing to do with OxyContin, having died before Purdue Pharma started selling the drug. In fact, his direct descendants did not profit from OxyContin either, since they did not have an ownership interest in the company when it was selling OxyContin. It was Arthur’s two younger brothers and their children and descendants who reaped the benefit.

Keefe’s rationale for focusing on Arthur until his death is that he pioneered the marketing techniques that later were used to sell OxyContin.  Roche had developed two minor tranquilizers to compete with Miltown (derisively referred to as “mother’s little helper”), Librium and Valium. These tranquilizers, especially Valium, became widely prescribed starting in the 1960s, but they can be abused and can lead to dependency or addiction. Of course, they are not as dangerous as opioids.

Arthur Sackler became rich from his company helping Roche to market Valium and then used some of his wealth for philanthropic purposes, especially for art museums. The tale of his business practices, including convincing doctors to prescribe Valium, interactions with the U.S. Food and Drug Administration, and secretly having part ownership of his principal competitor are fascinating to read.

The rest of the book is mainly about OxyContin, which when used as directed, provides time-released oxycondone to relieve pain. It was the main drug that Purdue sold, and the company did nothing to monitor its use, such as certain pharmacies and doctors dispensing and prescribing enormous amounts of the drug. Purdue continued to send their marketing teams to doctors’ offices to convince them of the safety and usefulness of the drug even though they knew it was being abused in dangerous ways. The company blamed those who became addicted on the addicts. 

All of this was a major factor in the opioid addiction crisis. For many years, the Sacklers and Purdue were able to fend off legal challenges from prosecutors concerned about what was happening in their communities. The problems eventually became too much for Purdue and it declared bankruptcy in 2019. None of the Sacklers were prosecuted for crimes. While they left the company, they were able to keep most of their wealth. However, to the extent it matters, the Sackler name was erased at many of the museums and other institutions which had benefitted from Sackler donations.

Keefe’s book is partly an indictment of the Sackler family. For example, he is quite harsh towards the granddaughter of one of the Sackler brothers, who is a documentary film maker. Madeleine Sackler has never had anything to do with Pharma, but of course some of her wealth is likely derived from what she inherited. At a minimum, she should probably be more upfront about that, but does that mean her films are forever tarnished?

The book does forcefully document the ways the legal system can sometimes let the rich get away with crimes. This is indicated in the prologue, which describes Mary Jo White, a former prosecutor who was appointed chair of the SEC by President Obama, assisting one of the Sacklers in a 2019 deposition.

When I read the prologue, I thought this deposition, just as Chekhov’s gun, would resurface at the end of the book. It does not. But Keefe does quote a lawyer as saying, “Everyone is entitled to a lawyer, but it doesn’t have to be you.” That will have to do.

Finally, the book reminds me of the mangled rendition of what Honoré de Balzac once wrote: “Behind every great fortune lies a great crime.” What Balzac actually wrote in Le Père Goriot was: “Le secret des grandes fortunes sans cause apparente est un crime oublié, parce qu'il a été proprement fait.” While this has been translated in various ways, a literal translation is: “The secret of great fortunes without apparent cause is a forgotten crime, because it was properly done.” In this book, Keefe is trying to make sure that the Sackler’s crimes are not forgotten.

The Lexington Column on the U.S. Budget and Debt and Deficits

This will be a brief note on the “Lexington” column in The Economist of February 4, 2023.  The article mainly hammers away at the political dysfunction of the U.S. government budget process: “Both parties have learned that, by luxuriating in polarisation, they can ignore that governing requires trust and compromise. Republicans can have their tax cuts, Democrats can have their spending, and they can blame each other for the debt.”

This is simplistic political analysis. For example, the Trump Administration was not adverse to spending, and deficit reduction has been more of note during Democratic rather than Republican Administrations. Tax cuts have been more characteristic of Republican administrations, but, after a tax cut that went too deep at the beginning of the Reagan Administration, it endeavored to increase revenues. And, parenthetically, I would note that the one of the best tax bills to pass Congress in the last 40 years (or more) was the Tax Reform Act of 1986, which required a bipartisan effort and was set in motion by Republican Treasury Secretaries Donald Regan and James Baker. (Some of its more notable features have since been jettisoned.)

In addition, there is the implied assertion that the current level of the debt is bad or dangerous and that the coming additions to the debt through future deficits is also bad or dangerous. Perhaps this assertion is correct, but the nearest the article comes to making this case is to point out that the debt to GDP ratio is high, that the debt held by the public is $24 trillion, and that the cost of servicing this debt represents 7% of federal outlays and that this will increase as interest rates go up. Numbers meant to be scary are not by themselves a convincing analysis.

Nevertheless, I am happy to note that Lexington did not refer to the headline figure of the debt limit ($31.8 trillion) but rather to debt held by “the public.” In the peculiar way the English language is used by the Treasury, the “public’ excludes government trust funds, such as Social Security, but does include the Federal Reserve Banks, which are technically “private” corporations. If you subtract out from the publicly held public debt the holdings of the Federal Reserve, the resulting number is sometimes referred to as the “privately held” public debt. It’s all very confusing.

For reference, here is my recent post about public debt numbers. A good, objective explanation of the statutory debt limit is in this Pew Research Center article, “5 facts about the U.S. national debt.”