Even though it has been a few weeks since I finished Patrick Radden Keefe’s Empire of Pain: The Secret History of the Sackler Dynasty (Penguin Random House, 2021), the book does not feel over for me. The book has not left me. Part of the reason why I still feel very much in the middle of this book is because the opioid crisis lives on, and we can see evidence of this everywhere. The other reason is because the litigation that this book outlines in such painstaking detail is ongoing, but one thing is made clear within Keefe’s book: those responsible for the opioid crisis are unlikely to ever pay for this crime of the century. 

In a brilliant three-volume book, Patrick Radden Keefe delivers the story of the Sackler family, an inordinately wealthy pharmaceutical family who are responsible for the advertising and creation some of the bestselling (and most abused) drugs in U.S. history: Thorazine, Librium, Valium, and, of course, OxyContin. In Book One: “The Patriarch”, Keefe outlines Arthur Sackler’s rise to pharmaceutical and advertising fame. In 1942, Sackler was a physician at Brooklyn’s Creedmoor Psychiatric Center and was attempting to change the way that schizophrenic patients were treated when he took a part-time job at McAdam’s, an advertising agency. McAdam’s had recently decided to focus exclusively on advertising pharmaceutical products, and they brought Sackler on in order to make that leap. Sackler’s strategy was to 

“Adopt to the seductive pizzazz of more traditional advertising—catchy copy, splashy graphics—and to market directly to an influential constituency: the prescribers… so, in selling new drugs, he devised campaigns that would appeal directly to clinicians, placing eye catching ads in medical journals and distributing literature to doctor’s offices. Seeing that positions were most heavily influenced by their own peers, he enlisted prominent doctors to endorses products. It was the equivalent, for physicians, of putting Mickey Mantle on a box of Wheaties. At Arthur’s direction, drug companies cited scientific studies (which had often been underwritten by the companies themselves) as evidence of the efficacy and safety of each new drug” (36). 

Reading passages like this filled me with dread because, as Keefe details, many of these strategies would be used by Arthur’s heirs to sell OxyContin. Keefe does not let us forget, while taking us on a journey through Arthur Sackler’s unethical and frankly criminal activities, that all of this was laying the groundwork for the disaster that would become OxyContin. Keefe also outlines in striking detail Arthur’s many conflicts of interest, including the medical newspaper he established in 1960 called Medical Tribune, wherein he would advertise on behalf of his clients at McAdam’s, Pfizer, to convince doctor’s that highly addictive narcotics like Valium and Librium were totally appropriate to prescribe for the average anxious housewife. This again sounds eerily familiar—many of these strategies would be utilized to sell OxyContin. Keefe draws an invisible line between Arthur’s early days and the dangerous precedents they set to the creation of OxyContin. This is what makes his book unlike any other on the opioid crisis. Empire of Pain seems to suggest that you cannot understand the opioid crisis without understanding Arthur Sackler and the ways that he falsified medical advertising. 

In Book Two: “Dynasty”, Keefe outlines the beginnings of Purdue Pharma, the Sackler-owned company that would eventually go on to manufacture OxyContin. Arthur’s brothers Mortimer and Raymond purchased Purdue Fredrick (this name would eventually be changed to Purdue Pharma) in 1952. Mortimer and Raymond purchased offices in Yonkers, and Raymond’s son, Richard, would come to work for the company after receiving his MD. Keefe’s portrait of Richard is chilling—his endless, ruthless, blind ambition to grow the company is just the tip of the iceberg. Keefe presents an emotionally immature, socially unaware, entitled sociopath in Richard. I appreciated the chance to get to know the person who holds the lion’s share of the blame for the opioid crisis because it helps you to understand how Purdue could (and continues to) deny that OxyContin is dangerous and addictive. Richard has a breathtaking ability to dissociate from the consequences of his actions. In fact, most of the family and their employees possess this ability. The way that Keefe presents the culture that was so a part of Purdue’s day-to-day operations helps you understand not only how a drug like this could be produced and sold in the way that it was, but also how the company could continue to deny the opioid crisis and their creation of it even as it was staring them in the face. 

Book Two further explains how the seeds were sown for the opioid crisis. Despite the fact that OxyContin was stronger than other opioids like morphine and Percocet, Purdue found that doctors had little knowledge of oxycodone (the opioid in OxyContin) and capitalized on this ignorance, instead suggesting to doctor’s that OxyContin was safer than other opioids because of the Contin slow-release system. This, of course, was proven to be a piece of fiction invented by the Sackler’s, and Keefe outlines in shocking detail how and why this was done. 

Keefe also outlines how the FDA approval process for OxyContin proceeded. This is another fascinating aspect of this text: it is filled with the history of pharmaceuticals in the United States, and Keefe explains in great detail how drug patents work, and how the FDA approves new drugs. The usual process of drug approval within the FDA is important to know, because as Keefe suggests, the process for OxyContin was anything but usual. So unusual, in fact, that the FDA employee who was responsible for OxyContin’s approval eventually quit the FDA and became an employee of Purdue Pharma. I appreciated Keefe’s professional and journalistic distance in moments like these ones when he must relay something so obviously unethical and egregious. But I also appreciated that Keefe is not so distant from the material that you cannot hear his voice coming through, as when he describes the first indications that OxyContin was creating an epidemic of addiction: 

“Nobody could say precisely where or how it started, but the first hints of it cropped up in rural Maine, in the Rust Belt of western Pennsylvania and eastern Ohio, in the Appalachian areas of Virginia, West Virginia, and Kentucky. The abuse spread, quickly, like some airborne virus, from one small community to the next. The regions where the problem began often had large numbers of people who are out of work, or who worked hard, manual-labour jobs, people who are disabled or chronically ill, people who are suffering from pain. As it happens, these were also precisely the kinds of regions that Steve May and other Purdue sales reps had targeted—regions that would be fertile terrain for OxyContin. In some cases, these communities also happen to have longstanding problems with prescription drug abuse. In some parts of Appalachia, people would pair an OxyContin with a Valium—one of Richard Sackler’s pills and one of his uncle Arthur’s. They called this the ‘Cadillac High’ (226).” 

You can hear Keefe’s sadness in this passage, and you can also hear his disgust. He is urging his reader to connect the dots between Arthur’s pharmaceutical advertising beginnings and Richard’s beyond corrupt practices, and he is also urging his reader to feel this crisis as more than hundreds of thousands of people dead. These people were targeted by Purdue with an FDA-approved drug. Keefe never lets his reader forget that Purdue was the predator and very particular communities were the prey. 

Book Three, “Legacy,” deals with the extensive fallout of OxyContin. This book discusses the many cases brought against the Sackler’s for their part in the opioid crisis, their appalling and inhuman responses, and explains where the company, as well as OxyContin, stands today. The amount of research that went into this book is staggering, and what it reveals will astound you. I thought I knew a good amount  about the opioid crisis and Purdue, but Keefe’s book taught me more than I ever wanted to know. More than this, this book laid out for me in startling detail how depraved human beings can be when there is money on the line. It reiterated to me how large corporations control the United States government. And it solidified for me that the creation and pushing of OxyContin is truly the crime of this century, the effects of which will be felt for generations to come. 

If you read one book from 2021, let this one be it. 

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Please add Empire of Pain to your Goodreads shelf, visit Patrick Radden Keefe’s website, and follow him on Twitter. 

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About the Writer: 

Jesyka Traynor is an academic living in Kingston, Ontario, Canada. When she’s not writing or researching her dissertation, she’s consuming all the true crime and non-fiction she can find time for. Jesyka holds two degrees in English literature and is currently pursuing a doctorate in contemporary Californian literature. Her work on women in twenty-first century true crime is forthcoming from Crime Fiction Studies.