prologue: the taproot

• Sackler family has decades of history known for their philanthropy; funded wings at the Louvre and the Met; schools for medicine and biomedical science at universities #concept/philanthropy #concept/public-health
  • How exactly they made their money + accumulated wealth was less known…
  • Purdue Pharma, the family business, did not carry their name, unlike their donations (hard to even find a connection on the company website)
  • 1996: Purdue introduced OxyContin; huge success; generated $35B in revenue
  • Three Sackler brothers (incl. father of Kathy Sackler), all doctors, purchased Purdue Frederick in the 1950s
• Only parallel to the class action lawsuits against Purdue re: opioid epidemic was that of the tobacco industry re: hiding risks of cigarettes, which led to $206B settlement
  • AG of NY, who named Sacklers as defendants in the case: OxyContin is "the taproot of the opioid epidemic"
• Part of practicing law is "distilling things to their essence" (but as a defendant, your job is often to avoid the essence)

book i: patriarch

chapter 1: a good name

• Arthur (oldest of the brothers) -> very entrepreneurial from a young age; worked in marketing and advertising
• Parents wanted their kids to be doctors (social prestige and doing good things)
  • Younger two brothers had trouble getting into medical schools in the US due to quotas on Jewish students
• Their father wasn't able to leave his sons with much money (Depression era, etc.), but he did give them a good name

chapter 2: the asylum

• Arthur and the brothers all eventually ended up working at a large asylum, Creedmore, where he was frustrated by the poor treatment options (lobotomies, ECT)
  • Through experimentation first with animals then with patients, they found that the mechanism of ECT might be the release of histidine, causing blood vessels to dilate and bring more oxygen to the brain -> directly administering histidine was actually pretty effective, even for patients who had not responded to any other treatments
  • Published >100 articles on this and got nice press coverage, by Arthur's previous marketing experiences; suggested they had "found a cure for insanity"

chapter 3: med man

• WWII changed business model of pharma companies like Pfizer that previously produced "raw" chemicals; enlisted to supply penicillin for the troops, so now producing a finished drug
  • The "miracle drug" era -> pharma companies looking for new + patentable chemical treatments, "ethical" medicines that were prescribed by doctors
  • Turned to advertisers to make patients and doctors aware of these; incl. a firm Arthur Sackler worked at and eventually owned
  • Sackler's strategy was to appeal directly to prescribers— ads in medical journals, literature at clinicians' offices, doctors' endorsements (physician-to-physician)
  • Emphasized name of the company in addition to the drugs; coined phrases like "broad-spectrum" antibiotics
  • Sackler eventually known for inventing the field of modern medical marketing
• Arthur saw the process not as advertising but as education
  • In his view, doctors were impeachable; there was no need to protect patients from potential conflicts of interest between pharma companies and prescribers
• When the Sacklers opened a research institute at the asylum, Arthur positioned himself somewhat behind-the-scenes (director of research rather than overall director); learning this is sometimes the best option when juggling many and potentially conflicting commitments
  • Continued to found organizations for medical news, publishing, research
• Despite adulation and admiration in most of his pursuits, Arthur faced Antisemitism in Washington
  • Had an eye for good people; as long as they were talented, other factors didn't matter
  • Hired many Jews, blacks, recent immigrants, people persecuted by McArthur (many "politically dubious people")
  • Hard person to work for: micromanaging, unsettling, didn't pay well ("Where else are you going to go?")
• Another secret: Sackler was close friends with the man who owned the main firm seen as his competition in pharmaceutical advertising (and he owned a significant part of it) -> they worked behind the scenes to divide up the industry to avoid conflicts of interest (can't represent two competing drugs)
  • The three brothers and Frolich(sp?) made a pact that as they died, the others would inherit their companies, and when they all did, the money would go to a charitable trust

chapter 4: penicillin for the blues

• Invention and marketing of Librium and then Valium by Roche — both "minor tranquilizers" that did essentially the same thing, but targeted to different ailments as to not induce self-competition
  • Also primarily marketed to stereotypical women
  • Marketed as having "no side effects" or potential for addiction, but this obscured evidence to the contrary
  • Sackler & co were able to avoid having the tranquilizers categorized as "controlled substances" until their patent expired
• Valium was behind most of the Sackler fortune, but Arthur spent his later days distancing himself from the drug
  • Eventually the public realized the danger, but it took awhile to see a drug prescribed by a doctor as one with potential for abuse
  • This source of $ was contrary to Arthur's self-portrayal as a "righteous man of medicine"
  • Response to claims of addiction to Valium: it's not the drug, it's the people with addictive personalities that are at fault

chapter 5: china fever

• Arthur's interest in ancient Chinese art -> near obsession with collecting it, which began to make his name more widely known
  • Also influenced his philanthropy: donating money to, e.g., Columbia to fund research and purchase art— all for the Sackler Collection
  • Generous, but also a practice of family branding (a lá the Carnegies, Rockefeller, Mellons, Morgans)
  • Prosperity over publicity

chapter 6: the octopus

• Sackler (and drug industry as a whole) came under scrutiny by investigative journalist John Lear (sp?) and the US government (late 1950s)
  • Entanglement of interests with FDA Chief of Antibiotics, pharma marketing, and authority as a doctor
  • False advertisement claiming endorsements by 8 doctors who didn't exist
  • Inquiry by congressman who lead the Anti-trust Committee revealed just how much the FDA/regulatory agencies pandered to pharma companies— even insinuating their own ad copy into speeches by FDA officials
  • Over 20 corporate entities received mail at the Sackler HQ building, few of which were obviously linked to the brothers -> comprised an "integrated empire" through which they could develop a drug, have it clinically tested, secure favorable reports, divide and advertising campaign, publish these articles and ads in their own medical journals, and use their PR influence to place ads in newspapers and magazines
• Arthur essentially talked his way out of any blame when he appeared in front of Congress

chapter 7: the dendur derby

• NYC's Metropolitan Museum of Art -> originally conceived of post-Civil War to give the US an art museum to rival those in Europe
  • Tension between its egalitarian mission (free, open to public) and exclusive club of robber baron backers who funded it
  • By the 1960s, the Met was struggling— needed $ for renovations, to pay its staff -> turned to Arthur Sackler
  • Sackler donated $150M (?) for a new Sackler Gallery, but also bought all the artworks to be shown (at 1920s price the museum had paid) and donated them back, all to be declared "gifts of Arthur Sackler" (attached his name to more items and a tax advantage, bc declared the items at current value)
  • Also got his own (secret) "enclave" in the Met to store his private art collection, along with an office and curator (though it was locked to museum staff)
• (If your name is attached, it's philanthropy, not charity.)
  • What philanthropy really buys is immortality.
• The US helped Egypt relocate 5 ancient temples that would have been flooded by a dam being built on the Nile -> government offered to donate one, the Temple of Dendur, as a token of gratitude
  • The Met wanted the temple, and ultimately won the bid for it
  • Controversy over where to place it and how it would be funded, esp. because Egypt went to war against Israel
  • Arthur Sackler immediately agreed to pay the $3.5M required (in return for the wing being named after them, etc. etc.; and paying the sum over 20 years) (again ended up being a great deal for them due to tax breaks, and not actually enough to fund the new museum restoration alone)
• Despite the donations, many still wary of Sackler due to the restrictions he put on his givings, sense that a scandal may be brewing

chapter 8: estrangement

• Rift grew between Arthur and his two brothers Mortimer and Raymond
  • One reason: Bill Frolich died, and the younger two inherited most of his company ISM, which had been Arthur's brainchild (Arthur had avoided officially being a part due to conflicts of interest, and there was a separate three-way pact between Frolich, Mortimer, and Raymond for international holdings) -> when ISM went public, Arthur got nothing

chapter 9: ghost marks

chapter 10: to thwart the inevitability of death

• 1987: Arthur Sackler died; "in media res"; no contact with brothers

book ii: dynasty

chapter 11: apollo

• Richard Sackler, son of Raymond, was a bit weird

chapter 12: heir apparent

• 1970s Purdue Frederick, led by Raymond Sackler & joined by his son Richard, was very profitable for the family; but specialized in un-glamorous drugs like laxatives, disinfectants
  • Quite conservative company
  • Raymond was intensely private, even more so than Arthur (aside from the philanthropy)
• Richard went to med school, but primarily interested in the business/management side
  • Seen as somewhat of a princeling, thoughtless; didn't have his father's leadership style
• Mortimer oversaw more research-focused pharma company in Europe developing a morphine pill: big step from current administration which required IV or shots; utilized new "Continus" pill coating that carefully regulated diffusion of drug into bloodstream: MS Contin
  • Allowed hospice patients to stay out of the hospital in their final days; lauded as extremely impactful
  • Sacklers moved to market the drug in the US, but wanted to avoid lengthy regulatory process required for new drugs -> framed it as an old drug (just morphine) with a new delivery mechanism
    • This grandfathering in of new twists on old drugs was in the process of being forbidden -> Purdue tried to beat the change, started manufacturing without any notice or permission and offered it for sale by 1984
    • 3 months later, got notice from FDA they weren't allowed to do this— but, because they now already had patients dependent on MS Contin, they were hesitant to pull it completely; Purdue successfully put pressure on the White House to be allowed to continue to sell the drug and just submit the new paperwork now
    • $107M/year in sale: first painkiller made the Sacklers that much richer

chapter 13: matter of sackler

• Upon Arthur's death, size of his holdings, debts, IOUs, verbal promises— all largely unknown by any one person— borrowed a lot and owned a lot; lack of transparency even between the brothers
  • Surprisingly to his children, left most of the estate to his 3rd wife (rather than Elsa, his first wife and longtime friend, and owner of half of his marketing company)
  • Lots of tension between all the heirs
  • All of this also at odds with the "Four Musketeers" agreement between the three Sackler brothers and Frolich (domestic between the four, international between all but Arthur), which did not much exist in spirit or letter anymore
• Arthur Sackler's heirs (foolishly) ended up selling their stake in Purdue to Mortimer and Raymond, right as the pain meds were taking off

chapter 14: the ticking clock

• "The patent cliff" -> large drop in revenue when pharmaceutical patent expires
• Richard Sackler -> main proponent moving Purdue towards pain control
• Medical community starting to reevaluate how pain was seen + treated: until now , always just a symptom of an underlying issue
  • America is in a "silent epidemic" of pain from various injuries, cancer, etc.
  • Doctors reluctant to administer morphine because it's seen as an end-of-life drug, addictive -> MS Contin addressed therapeutic gap
  • "Morphine is not addictive when used to treat pain," similar to Arthur's take on Valium addiction
• MS Contin was immediate success in US, and Purdue immediately started looking into new controlled-release opioids for when the patent expired
• Kathy, daughter of and proxy for Mortimer (also MD from NYU), increasingly at odds with Richard, son of Raymond; both less kind than their fathers
  • Kathy claims to have proposed oxycodone as the next opioid to try with the controlled release system: more potent cousin of morphine, currently only available mixed with aspirin or acetaminophen, which are toxic in large doses
  • New generation established Purdue Pharma, a new company, more focused on "innovative products"
• 1993: named the new drug OxyContin, initially intended as an alternative to Percocet, for cancer pain…
  • BUT, confidential initiative to also target all other types of chronic, non malignant pain (after initial FDA approval) as enormous untapped market
  • Needed to "establish a body of literature" to support this aim, esp. because oxycodone was so much stronger than morphine, and perceived as very addictive

chapter 15: the god of dreams

• Poppy from ancient history known for its medicinal properties, not only associated with sleep and as a painkiller, but also as a poison, with death and suicide
• Late 1800s, morphine (derived from opium) widely used in war; millions of veterans returned to the US addicted
  • Then, chemists in Germany (Bayer) refined morphine into a new drug, heroin— marketed as a safer alternative to morphine (in reality, heroin was just as addictive as morphine and 6x as strong)
  • By the 1910s, people realized this was. A mistake, heroin stopped being sold
  • "I'll die young, but it's like kissing God." — comedian Lenny Bruce (he did die young, from a morphine OD)
• Richard Sackler devoted himself to the drug with a fervor… from his coworker: "You need a vacation, and I need a vacation from your email."
• Marketed OxyContin against MS Contin, the first time this was done, to completely upend the pain management industry
  • Didn't have the stigma of morphine, the association with death and addiction… it's "personality" was as weaker than morphine, more approachable
  • Purdue took advantage of this misconception; purposefully did not market it to cancer patients in order to preserve it
  • Richard et al. continued to cultivate the group of physicians that agreed with their new vision for pain management
• Once OxyContin was approved for cancer pain, could be prescribed by doctors for anything
  • "Insert" for the drug contained an unprecedented amount of promotional material, from very suspect negotiation and meetings by Purdue with FDA officials
  • Extremely expedited approval in 11 months in December 1995; head FDA official responsible for the approval ended up working at Purdue a few years later

chapter 16: h-bomb

• Sacklers owned a chemical factory in Jersey; bad working conditions, etc. eventually led to tragic explosion killing several workers -> no expressions of condolences or responsibility by the Sacklers, just tried to silently close the factory
• Raymond Sackler granted honorary knighthood by the Queen of England soon after

chapter 17: sell, sell, sell

• Sales team seen as most important part of Purdue
  • No medical or pharmaceutical training, but goal was to influence doctors to change their prescribing
• OxyContin sold as the painkiller "to start with and to stay with" — not an extreme option
  • "The delivery system is thought to reduce the abuse liability of the drug." (FDA-approved claim on the drug label with no data backing it up), justified because "abuse is caused by the peak-and-trough phenomenon" and their delivery system avoids the immediate high
  • Lots of "non-branded literature" that was actually funded by Purdue; sent doctors to conferences and meetings… funded by Purdue; offered OxyContin-branded "swag"
  • The company was selling "hope in a bottle" — a safe and effective treatment for pain
  • Especially effective in targeting general practitioners, family physicians who weren't pain experts; utilized data from the Sackler-owned ISM to identify "whales" who prescribed a lot of opioids (or were naive about them altogether)
• Offered no cap on compensation for sales reps, unlike most other companies
• The drug seemed to be miraculous— the company got letters from people who "got their life back" after taking Oxy
  • Used these messages in video testimonials
  • Offered free samples (like heroin, Valium) -> "acquaint" patients with the drug…
  • Always urged doctors to "titrate up" doses; offered pills from 10 to 160 mg (which was "a lot")
• Exponential sales growth after introduced through 2000
  • Eventually, primary barrier to growth was product supply
• Richard Sackler wanted (boldly) to try to sell the drug OTC in Germany
  • Guy who invented the drug was skeptical— "we don't actually have evidence that it has no to low abuse potential"

chapter 18: ann hedonia

• People very soon discovered (and/or were told, through a warning on the bottle) that one could easily crush the pills to bypass the controlled release mechanism and get an immediate hit of oxycodone
• Since launch of drug, sales reps and Purdue heard reports of abuse, though they denied this
  • By 2000, problem was too big to ignore
  • Richard Sackler's response, like Arthur's to Valium abuse: nothing intrinsically addictive about the drug, it's the addictive personality of the abusers -> response would be to crack down on the abusers; claimed that any other explanation was a media narrative against Purdue
  • "Abusers aren't victims, they are the victimizers."
  • Took similar view as libertarians on gun manufacturers (all Oxy having been produced legally and by Purdue.. but guns don't kill people, people kill people)
• Problem with this view is that many people who started taking Oxy exactly as prescribed became addicted
• Evidence that addictive potential for the drug was intrinsic: marketed as providing 12 hours of pain relief; however, they had data showing the effects did not last this long for all patients, but only for 8
  • 12 hour dosing was a main selling point of the drug, so they ignored this data
  • However, when it was being taken every 12 hours but only provided 8 of relief, patients experienced exact peak-and-trough pattern that caused addiction (withdrawal symptoms between doses)
  • Many doctors prescribed 3 pills a day off label… to the sales reps, just more pills being sold
  • Purdue started calling these withdrawal symptoms "pseud-addiction," that could be solved by taking higher doses
• Investigative reporter Barry Meier who was breaking this story got insider tip from within Purdue revealing that the top 10 sales reps were responsible for precisely the epidemic hot spots
  • Many "pill mill" clinics that gave prescriptions to anyone who asked— Purdue was warned about this, but sales only increased
  • Only explanation is that sales were so high because of the abuse (despite claims of "hammering the abusers")
  • Meier started looking into the Sackler family, surprised to learn about their philanthropic reputation…

chapter 19: the pablo escobar of the new millenium

• Lawyers who initially were investigating Purdue's role in the opioid epidemic soon started working for them
• Purdue's strategy was to try to "bind Purdue to the trajectory of the pain management movement" to prevent limitations on their access to oxycodone
  • Also tried to destroy any paper trail of their knowledge of addictive use of Oxy
• Discredited any witnesses/employees who raised concerns by painting them as unstable, etc.
• Early 2000s, Sackler name was still not publicly linked to Oxy
• Richard Sackler, talking to his friend: "Addicts want to be addicted. They get themselves addicted, over and over again."
• 2003: Barry Meier published groundbreaking book Painkiller on the opioid epidemic -> Purdue starting calling bias, bad reporting etc. on the Times, his employer; Meier told he couldn't write about painkillers anymore because it was a "conflict of interest" (persuaded by Purdue)

chapter 20: take the fall

• Shortly after 2001, Brownly {sp?)} appointed AG of western region of VA by Bush
  • VA prosecutors were bringing charges against doctors, pharmacists, dealers, traffickers, thieves, pain pills — Oxy at the center of them all
  • Brownly wanted to know who was making it -> connected some of the guilty doctors as being speakers for Purdue
  • Prosecutors are "motivated by a complex brew of principle and desire." … and going after Purdue satisfied both
• Brownly's team moved from civil to criminal investigation of Purdue
  • After subpoena, Purdue sent millions of pages of files, trying to bury the lawyers in paperwork— but they handled it systematically and issued more specific subpoenas
  • Purdue tried to appeal directly to James Comey at the Dep't of Justice (revolving door between law firms and government), but Comey didn't budge
• Investigstors discovered that the entire story Purdue was "selling" to the authorities about their knowledge of Oxy's abuse and advertising strategies were lies
  • Incl. their own internal studies showing lack of efficacy of the drug, withdrawal symptoms— completely lied about in drug documentation
  • Purdue even tested how much narcotic payload could be dosed by dissolving and injecting the drug, but they officially claimed this wasn't even possible
  • Discovered troubling ties between FDA official Curtis Wright and Purdue; hinted at secret deal offering Wright a job
• Call notes from sales reps revealed the fraudulent marketing was not "a few bad eggs," but rather corporate policy— training content even instructed this
• Even claims of actual pain management were often false: many testimonials didn't even take Oxy long term or themselves became addicted
• By 2006, Brownly wanted to file felony charges against the three executives presented as the public face of Purdue and the company itself
  • No potential repercussions against shareholders, because Purdue still privately held
  • Also filed for a fine of >$1.5B (against profits already made on Oxy)
  • Hoped these executives could be persuaded to flip and help implicate the Sacklers themselves
• However: Purdue went over their heads to the Dep't of Justice to make a deal (which no one would take credit for later), forcing Brownly to drop the felony charges against the individuals
  • Brownly refused to fold to additional pressure to delay the case, which almost got him fired for political reasons
• Ultimately, Purdue plead guilty to felony charge of misbranding and paid $600M fine, the three execs to misdemeanors of misbranding and 12 year ban from working with Medicaid, etc.
  • HOWEVER: they played the name game again, and had Purdue Frederick plead guilty & die, while Purdue Pharma had no consequences
  • Sackler name mentioned nowhere in the statement of facts
  • The three execs "took the fall" knowing that the Sacklers would "take care of them," and indeed they each got multi-million dollar payments from the Sacklers
  • Sanctions ultimately had very little impact on the company or its practices

book iii: legacy

chapter 21: turks

• After the guilty plea, sales continued to boom; new sales reps; etc.— "ABC, always be closing"
• Opioid crisis continued to intensify in the US
• Purdue had evidence of corruption at many clinics and pharmacies, but did not restrict flow of Oxy to a single one
• Sacklers continued to "milk" the company rather than reinvesting, with tension between the two sides (Raymond + Mortimer)
  • Esp. as patent began to be challenged with generics and oxycodone rx numbers flattened, pressure to further increase sales (hired McKinsey..)

chapter 22: tamperproof

• Purdue very quietly switched the formulations for Oxy to one with a new coating, more "tamperproof" OxyContin OP— but didn't want to make a big deal about it less they rhetorically admit to abuse being an issue at all
  • Essentially turned into a gummy bear when tampered with
  • FDA once again permitted them to make unfounded claims, this time on abuse reduction
  • Reformulation didn't, however, prevent patients from simply taking too many pills, which was the primary form of abuse
• May have seemed altruistic, but really a strategy to keep the patent, which expired in 2013, "evergreen"
• Sales of new formulation dropped 25%— implying until then, 1/4 of their profit came from abuse
  • Seemed like far too little, too late.. already so many people exposed to the drug, and simply moved from Oxy to heroin
  • Huge surge in trafficking of heroin from Mexico; sales tactics "eerily similar" to those used by Purdue
• Analysis of 2010s heroin epidemic showed that ~3/4 of users had started by abusing prescription painkillers

chapter 23: ambassadors

• Sacklers continued to successfully distance their name from Purdue and OxyContin
• As market in US seemed to plateau, largely due to growing caution of doctors, focus turned to the Sackler's international company, Mundy Pharma
  • Ran the same playbook they had in the US, 20 years later, even with the same fraudulent and now debunker claims; flew out "pain ambassador" doctors to educate others about the benefits of strong opioids
  • China was seen as the biggest opportunity

chapter 24: it's a hard truth, ain't it

• 2015, state of Kentucky suing Purdue due to deceptive marketing (case started 8 years prior)
  • Purdue ordered demographic study to prove the case shouldn't be tried there, but it proved revealing in unexpected ways: nearly 30% of community knew someone who had died from OxyContin OD; 70% said its effect on the community was devastating
  • Richard Sackler eventually forced to testify
  • Purdue ended up settling for $12M AND got all the records sealed, including Richard's deposition
• LA Times published series of investigative pieces on the "Region Zero" list of suspect prescribers, Purdue's knowledge of Oxy's <12 hour efficacy time, Murdy Pharma strategy
  • Caused some internal turmoil with younger execs and employees, who wanted to remake the company in a more modern light, vs the old guard loyal to the Sacklers
  • Some of this old guard seemed to not have any talent or role, yet incredible job stability
• Sacklers increasingly out of touch with public opinion; surrounded themselves with yes men
  • New guard pushed for changes in corporate culture; addressing the opioid crisis and advocating for "appropriate use" of Oxy, but old guard was extremely resistant— and move towards acknowledging existence or compassion about the crisis would be a concession
  • Some of the original doctors espousing opioids as the panacea for pain management even began to admit there simply wasn't data on the efficacy of opioids
• CDC began efforts to draft "unbiased" guidelines for opioid use without any input by the pharma companies who sold them —> concerning to Purdue
  • Up till then, lobbyists against restrictions on opioid drugs had spent more than those against gun control
  • CDC advocates for using opioids as last resort, lowest dose for shortest time -> threat to whole painkiller industry; Purdue allied with competitors to counter, but guidelines still eventually released in 2016
  • Still had to be careful not to swing to hard in the other direction, which could drive patients to the black market or prevent valid use of opioids
• New CEO, back to old guard, strategized to consolidate opioid market as other companies withdrew due to public backlash

chapter 25: temple of greed

• Early 2017, first articles published that really highlighted connection of Sackler to OxyContin, in contrast to their philanthropic reputation
  • First public fissure between "Arthur" side of the family and Mortimer/Raymond: Arthur's daughter and widow spoke out against Purdue; denied any culpability of Arthur, despite him establishing many of the practices that OxyContin utilized
  • "A bit rich for the Valium Sacklers to be getting morally huffy about their OxyContin cousins." — Nan Goldin
• Sacklers especially upset about negative coverage over new pediatric indication for Oxy, which likely was another patent extension strategy but they said was just "required by FDA guidelines"
  • Not willing to diversify and refused any options presented by the company to the board, largely because they were t profitable enough
• Still, not much backlash from institutions receiving their philanthropic gifts until Nan Goldin led protest in the Met

chapter 26: warpath

• Tasmania -> special poppies grown that produce high levels of oxycodone precursor, source for much of it
• Sacklers tried to downplay the opioid market share that Purdue held; suggested the true giants were generic manufacturers
  • However, Sacklers secretly owned Rhodes Generic, which was one of the biggest manufacturers of generic opioids, incl. IR oxycodone
  • Regardless of comparative market shares, all other companies were following the lead and strategy of Purdue: "OxyContin created a market."
• Michael Moore -> AG who took on big tobacco, after Deep Horizon oil spill got settlement out of BP
  • Saw analogies with Purdue; but Purdue more saw parallels with gun manufacturers, who successfully had lobbied they are not responsible for the actions of those who bought their product
  • Moore tried a new strategy, pooled resources with many groups (multi-district litigation) and brought cases against not just Purdue but other manufacturers, wholesalers, etc.
• Sacklers finally starting to get worried— even Purdue's counsel claimed "unless the family starts saying something, anything the company says will be drowned out by the family's silence."
  • Slowly they all resigned from the board
• Protests led by Nan Goldin started working -> many institutions at least said they'd stop accepting more money from the Sacklers— even the Met
  • Gathered support form more artists
• Ohio: 20% of population had received opioid rx
• Purdue cut back significantly on its sales force, attempted to reinvent themselves— but they would still make millions from carryover sales

chapter 27: named defendants

• Biggest threat surfaced Jan 2019: AG of MA for the first time named 8 Sacklers as defendants
  • Internal papers from Purdue revealed just how involved the Sacklers were in the business, and judges refused to keep them sealed
  • Evidence that, as early as 2006, Sacklers had began to siphon money from Purdue offshore to protect their fortune
  • More institutions, even Purdue's banker (JP Morgan) cut ties… still zero remorse by any of the family

chapter 28: the phoenix

• More and more (2000!?) states, counties, tribes, etc. began suing Purdue and the Sacklers personally
  • Rather than settling each individually, David Sackler proposed collectively addressing them all by declaring bankruptcy and turning Purdue into a public trust and giving a large sum of money ($10-12B) to address the opioid epidemic; Sackler's would get immunity in return
    • However, very little of this money would be theirs personally (contingent on selling Mundy and even by Purdue continuing to sell Oxy)
    • They would admit to no wrongdoing, essentially buying silence
    • Sacklers' major leverage was that Purdue was nearly bankrupt due to constant lawsuits and siphoning of money by the family, which would usually halt litigation -> states would have to fight for years over assets in bankruptcy court
  • Many state AGs felt as though taking the deal was the best option
    • Despite Purdue historically and concurrently donating to R and D AG lobbies, some partisan divide with more R states willing to accept settlement
    • Lots of politics + negotiation going on in the background between parties on both sides, manipulating bankruptcy law

chapter 29: un-naming

• Evidence that OxyContin was a causal factor in opioid epidemic -> comparing the handful of states with triplicate programs (doctors had to fill out special forms filed with states when prescribing Schedule 2 narcotics): TX, ID, IL, NY, CA
  • Identified by Purdue in internal docs as a barrier to entry to opioid market -> concentrated efforts elsewhere
  • In years following Oxy launch, these states had 50% less rx than average; overdose rates uniquely low
  • Even after program ended, long term effects with lower abuse rates; even in 2019, lowest rates of opioid deaths overall
• 2017–2019: continued protests; the Louvre "sunset" the Sackler name; Smithsonian minimized its use; Tufts stripped the name from 5 buildings
• In bankruptcy court, lawsuits continually suspended
  • Sacklers estimated to have taken $13B+ from Purdue, now worth only $1B
  • Thousands of claims submitted by individuals and institutions who were affected by Oxy
    • UHC alone stating 100k+ members had been prescribed opioids and then been diagnosed with opioid abuse disorder
    • Dep't of Justice filed too, due to criminal misconduct in marketing, targeting known bad actors (same as usual)
    • However, pressure from Trump admin on DOJ to wrap up the cases -> still no criminal charges against individual execs (like 2017 all over again)
  • Unfortunately, this protection by the government had precedent
• TN senator, quoting Upton Sinclair: "… a man has difficulty understanding something, if his salary depends on him not understanding."
• Victims didn't want money, they wanted truth— would never be able to collect "enough" money (est. cost of opioid epidemic >$1T)
• Irony in Purdue becoming a public trust: finally fulfilling the "Four Musketeers" agreement between the original 3 Sackler brothers and Bill Frolich

afterword

• Came to this project while studying Mexican drug cartels, analyzing them as businesses
• Goal here was to chronicle the opioid epidemic through the story of the three Sackler generations
  • Not trying to keep blame from other pharma companies, the FDA, pharmacies that contributed to the epidemic, rather highlighting the pioneering role of Purdue
  • Continuity of tactics used to manipulate the press and regulatory officials
  • "Fog of collective denial" at Purdue — notable absence of whistleblowers: too much for the human conscience to bear?
  • No cooperation by the Sacklers in reporting this book; "boycotted" factchecking efforts
  • All evidence from documents produced during discovery, court papers; hundreds of personal interviews; all independently factchecked; FOI requests