podcast Peter Attia 2021-12-06 topics

#186 - Patrick Radden Keefe: The opioid crisis—origin, guilty parties, and the difficult path forward

Audio

Show notes

Patrick Radden Keefe is an award-winning staff writer at The New Yorker and the bestselling author of Empire of Pain: The Secret History of the Sackler Dynasty . In this episode, Patrick tells the story of the Sackler family and Purdue Pharma – makers of the pain management drug OxyContin, providing the backdrop for the ensuing opioid epidemic and public health crisis. He reveals the implicit and sometimes explicit corruption of all parties involved in the development, approval, and marketing of OxyContin, leading to a cascade of unintended consequences including addiction and death. He explains the unfortunate lack of accountability for the current crisis, as well as what it all means for those with legitimate pain management needs. Finally, he examines the difficult path ahead towards finding a solution.

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We discuss:

Patrick’s investigation into distribution and use of drugs in our society [3:55];
The scale of of the opioid crisis [9:15];
The Sackler brothers: family life, career in the pharmaceutical industry, and role in the current crisis [11:45];
Purdue Pharma: origins, early years, and move towards pain management drugs [17:30];
The development of OxyContin: its conception, marketing, and the controversy around the FDA approval process [25:30];
Early reports of OxyContin addiction and unintended consequences and how Purdue Pharma sidestepped responsibility [40:45];
The many paths to addiction and abuse of OxyContin and the ensuing downfall of Purdue Pharma [47:15];
Peter’s personal experience with OxyContin [57:00];
Pain—the “fifth vital sign,” how doctors are trained in pain management, and the influence of money [1:08:00];
Other players that helped facilitate the eventual opioid crisis [1:16:15];
Lack of accountability following the investigation and prosecution of Purdue and the Sackler family [1:23:30];
Legacy of the Sackler family and their disconnect from reality [1:34:45];
Patrick’s views on the regulation and use of pain management drugs [1:42:15];
The difficult path forward [1:44:45]; and
More.

Show Notes

Intro notes

The guest this week is Patrick Radden Keefe, an award-winning staff writer at The New Yorker magazine and a New York Times bestselling author
His most recent book is about the opioid epidemic It’s a New York Times bestseller, Empire of Pain: The Secret History of the Sackler Dynasty
It’s a New York Times bestseller, Empire of Pain: The Secret History of the Sackler Dynasty

Figure 1. Patrick’s book about the opioid epidemic. Image credit: Amazon.com

Peter has been wanting to do a podcast on the opioid epidemic for some time, and he’s been trying to think of the right way to do it
Recently, he saw the HBO documentary, The Crime of the Century , and thought it was a really good and thorough overview of the problem

Figure 2. Movie Poster. Image credit: by Studio and or Graphic Artist

This is a problem that has many layers to it, right? It has the organizations that actually make these drugs, so the producers and the pharma companies It has the organizations that distribute these drugs between the producers and the end-stage or end-use retailers, so the intermediaries It has the retail side of things, where these drugs are purchased The physicians who prescribe these drugs The patients who use these drugs The enforcement agencies that regulate them The FDA that approves these drugs The medical advocacy groups that provide guidance to physicians about them
Consider the landscape of this problem and all of the actors just listed, each one of them plays some role in the current situation Half a million people have died in the past 25 years from opioid overdose Opioid overdose now represents the leading cause of accidental death in the United States Ahead of car accidents, gunshots, and things like that
Patrick’s book goes straight to the heart of the matter to explain: How did this begin? What was the thin end of the wedge that created this epidemic? He makes a very compelling case that it was the company, Purdue Pharma, a privately held company run by the Sackler family
This episode will discuss at great length the history of the Purdue Pharma Company and its management team About the implicit and sometimes explicit corruption that existed About the other players in this channel, the physicians, the regulators, the politicians none of whom really get off scot-free in this assessment
This is a bit of a depressing episode There is not much optimism that a solution is in hand and that 5 years from now, one will look back at this and marvel at how easily it was able to be solved
Peter feels it is important to expose and shed some light on how the opioid crisis came to be
It has the organizations that actually make these drugs, so the producers and the pharma companies
It has the organizations that distribute these drugs between the producers and the end-stage or end-use retailers, so the intermediaries
It has the retail side of things, where these drugs are purchased
The physicians who prescribe these drugs
The patients who use these drugs
The enforcement agencies that regulate them
The FDA that approves these drugs
The medical advocacy groups that provide guidance to physicians about them
Half a million people have died in the past 25 years from opioid overdose
Opioid overdose now represents the leading cause of accidental death in the United States Ahead of car accidents, gunshots, and things like that
Ahead of car accidents, gunshots, and things like that
How did this begin?
What was the thin end of the wedge that created this epidemic?
He makes a very compelling case that it was the company, Purdue Pharma, a privately held company run by the Sackler family
About the implicit and sometimes explicit corruption that existed
About the other players in this channel, the physicians, the regulators, the politicians none of whom really get off scot-free in this assessment
none of whom really get off scot-free in this assessment
There is not much optimism that a solution is in hand and that 5 years from now, one will look back at this and marvel at how easily it was able to be solved

Patrick’s investigation into distribution and use of drugs in our society [3:55]

Patrick has always been interested in drugs as a subject The way in which drugs fit into our society How we feel about them Which drugs are licit, which drugs are illicit
He wrote a big piece a number of years ago about the legalization of cannabis in Washington State In The New Yorker in 2013, Buzzkill: Washington State discovers that it’s not so easy to create a legal marijuana economy
He is very interested in this idea that you have this existing industry, this pot industry that’s been around for decades, and with the stroke of a pen at midnight it’s legalized What does that look like? How does it turn into a taxed and regulated economy?
The way in which drugs fit into our society
How we feel about them
Which drugs are licit, which drugs are illicit
In The New Yorker in 2013, Buzzkill: Washington State discovers that it’s not so easy to create a legal marijuana economy
What does that look like?
How does it turn into a taxed and regulated economy?

Mexican drug cartels

He had done a lot of writing on Mexican drug cartels Before he was full-time at The New Yorker , he did a cover story for The New York Times Magazine in 2012 about the Sinaloa drug cartel, Cocaine Incorporated To put this in context, at the time he had to explain to the editors of The New York Times Magazine who Chapo Guzmán was
He wanted to do sort of a Harvard Business School case study of a cartel He wanted to look at it as a multi-billion dollar transnational commodities enterprise He was really interested in how they diversified and how vertically integrated they were
The Sinaloa cartel dealt in cocaine, marijuana, heroin, and methamphetamine
One of the questions that grew out of that research had to do with the surge in heroin After 2010, huge volumes of Mexican heroin started coming across the border in ways that hadn’t been seen before in the US; this was the riddle he started with He started with this question of why is there a sudden uptick in heroin trafficking in the US The answer was the opioid crisis
Before he was full-time at The New Yorker , he did a cover story for The New York Times Magazine in 2012 about the Sinaloa drug cartel, Cocaine Incorporated To put this in context, at the time he had to explain to the editors of The New York Times Magazine who Chapo Guzmán was
To put this in context, at the time he had to explain to the editors of The New York Times Magazine who Chapo Guzmán was
He wanted to look at it as a multi-billion dollar transnational commodities enterprise
He was really interested in how they diversified and how vertically integrated they were
After 2010, huge volumes of Mexican heroin started coming across the border in ways that hadn’t been seen before in the US; this was the riddle he started with
He started with this question of why is there a sudden uptick in heroin trafficking in the US The answer was the opioid crisis
The answer was the opioid crisis

Complex web of entities involved in the opioid crisis

He started out with an inquiry that was solidly grounded in the realm of the illicit drug trade and found his way into the world of the FDA regulated legal drug trade with OxyContin and Purdue Pharma So he started looking into the origins of the opioid crisis He then discovered that this company (Purdue) was owned by the Sackler family This blew his mind, the idea that this family that’s quite well known for philanthropy had made such a huge fortune on a drug with such a controversial legacy
A long time ago when Peter was trying to get his mind around how many actors there were in the opioid crisis, he drew on a piece of paper It started on the left with the producers Not illicit chains but pharma companies of which Purdue was the champion of them Then there were the distributors or intermediaries The McKessons and the Cardinals of the world He actually knew a lot about McKesson through a previous life He was intimately familiar with what companies like McKesson did and how they were able to distribute products from the producers to the retail, the pharmacy, the CVSs of the world, so that became the third actor The 4th actors were the FDA (the approval process of the drug) and the DEA (enforcement) There are policymakers that create the policies that allow these entities to exist There are the providers, people that write the prescriptions for these things And ultimately there are the patients
The study of Purdue Pharma and the Sacklers, more than any other single entity in this entire chain he just explained, can provide a greater context of what we’re up against
Patrick notes that the nuance of all the actors in this crisis often gets lost
He writes stories where his interests lead him, stories he thinks are interesting and important and that will be interesting to readers
He doesn’t claim his work is the be-all and end-all in understanding the opioid crisis This is an incredibly complex public health crisis that has unfolded over the course of a quarter of a century
So he started looking into the origins of the opioid crisis
He then discovered that this company (Purdue) was owned by the Sackler family This blew his mind, the idea that this family that’s quite well known for philanthropy had made such a huge fortune on a drug with such a controversial legacy
This blew his mind, the idea that this family that’s quite well known for philanthropy had made such a huge fortune on a drug with such a controversial legacy
It started on the left with the producers Not illicit chains but pharma companies of which Purdue was the champion of them
Then there were the distributors or intermediaries The McKessons and the Cardinals of the world He actually knew a lot about McKesson through a previous life He was intimately familiar with what companies like McKesson did and how they were able to distribute products from the producers to the retail, the pharmacy, the CVSs of the world, so that became the third actor
The 4th actors were the FDA (the approval process of the drug) and the DEA (enforcement)
There are policymakers that create the policies that allow these entities to exist
There are the providers, people that write the prescriptions for these things
And ultimately there are the patients
Not illicit chains but pharma companies of which Purdue was the champion of them
The McKessons and the Cardinals of the world He actually knew a lot about McKesson through a previous life He was intimately familiar with what companies like McKesson did and how they were able to distribute products from the producers to the retail, the pharmacy, the CVSs of the world, so that became the third actor
He actually knew a lot about McKesson through a previous life
He was intimately familiar with what companies like McKesson did and how they were able to distribute products from the producers to the retail, the pharmacy, the CVSs of the world, so that became the third actor
This is an incredibly complex public health crisis that has unfolded over the course of a quarter of a century

The scale of of the opioid crisis [9:15]

At least a half a million people who’ve died from opioid overdoses since the mid to late 1990s
By some estimates, there are two plus million Americans today struggling with an opioid use disorder of one sort or another
Opioids are a pretty capacious category This includes regulated drugs like OxyContin and fentanyl that comes in from China or Mexico It’s also heroin
Think about the death toll today, the Sacklers would be quick to say, today, people are dying in very large numbers from heroin and fentanyl overdoses, not from OxyContin or from most prescription painkillers
This problem has transitioned into an illicit drug problem
So why did Patrick pick OxyContin? Why pick the Sacklers? Because it’s an interesting story
He’s interested in the fact that this was a family, and the family dynamics are interesting in part because of the philanthropic legacy There’s this kind of disconnect (or there was until recent years) between the reputation that the family had and what I would argue as the reality of their business
Most importantly, he thinks OxyContin was sort of the tip of the spear, the kind of nuance that often gets lost
It can be possible to stipulate that today the opioid crisis is a heroin and fentanyl crisis
Keep in mind the idea that absent OxyContin, the opioid crisis might not be what it is today OxyContin was the kind of first-mover in terms of changing prescribing habits in the United States in a way that had really fundamental consequences and ultimately built up a market for these drugs This market eventually migrated to illicit sources of supply This is the reason he thinks there is a special role that Purdue and the Sacklers played in the crisis But this doesn’t suggest that there isn’t blame with all those different buckets mentioned earlier
This includes regulated drugs like OxyContin and fentanyl that comes in from China or Mexico
It’s also heroin
Because it’s an interesting story
There’s this kind of disconnect (or there was until recent years) between the reputation that the family had and what I would argue as the reality of their business
OxyContin was the kind of first-mover in terms of changing prescribing habits in the United States in a way that had really fundamental consequences and ultimately built up a market for these drugs
This market eventually migrated to illicit sources of supply This is the reason he thinks there is a special role that Purdue and the Sacklers played in the crisis But this doesn’t suggest that there isn’t blame with all those different buckets mentioned earlier
This is the reason he thinks there is a special role that Purdue and the Sacklers played in the crisis
But this doesn’t suggest that there isn’t blame with all those different buckets mentioned earlier

The Sackler brothers: family life, career in the pharmaceutical industry, and role in the current crisis [11:45]

The 3 Sackler brothers are Arthur , Raymond , and Mortimer
They were the children of immigrants; their parents had come over from Europe at the turn of the last century and settled in Brooklyn They were Jewish The parents didn’t speak English well; they spoke Yiddish in the home They valued education and meritocracy
There are these kinds of very American mythical contours to the early parts of this story, where there’s a family that came with nothing and had an expectation that within the span of one generation, they would build an empire and make their mark on the country and the world
Arthur later said that from the age of four, he knew he would be a doctor There was a sense that there was kind of nothing as prestigious and virtuous as being a doctor There was a real veneration in this family for the role of the physician in society
They grew up against the backdrop of the Great Depression There’s a period where their father loses everything And so there was an expectation that the brothers have to go out there and hustle and make money and have jobs All three brothers worked multiple jobs For Arthur Sackler, it’s like he squeezed four or five lifetimes into one lifetime in terms of everything that he did
They end up eventually in the pharmaceutical business
But the way they get there is through pharmaceutical advertising and marketing This starts when Arthur Sackler is in high school, he gets jobs on the student publications He is at a huge high school, Erasmus Hall High School There are 6,000-7,000 students in Brooklyn, in Flatbush He gets jobs on the student magazine and the student newspaper, but he becomes the advertising manager Think about it, there are 6 or 7,000 students that he can reach; this was a real job This is where the hustle starts with Arthur
All 3 brothers end up becoming psychiatrists, practicing as psychiatrists But they pretty quickly pivot into commerce
There is this amazing moment early on, a pattern that Arthur goes and he does something, and then he brings his brothers in with them This starts in high school He’s got more jobs than he can handle so he starts handing them off to the brothers
They were Jewish
The parents didn’t speak English well; they spoke Yiddish in the home
They valued education and meritocracy
There was a sense that there was kind of nothing as prestigious and virtuous as being a doctor
There was a real veneration in this family for the role of the physician in society
There’s a period where their father loses everything
And so there was an expectation that the brothers have to go out there and hustle and make money and have jobs All three brothers worked multiple jobs For Arthur Sackler, it’s like he squeezed four or five lifetimes into one lifetime in terms of everything that he did
All three brothers worked multiple jobs
For Arthur Sackler, it’s like he squeezed four or five lifetimes into one lifetime in terms of everything that he did
This starts when Arthur Sackler is in high school, he gets jobs on the student publications He is at a huge high school, Erasmus Hall High School There are 6,000-7,000 students in Brooklyn, in Flatbush
He gets jobs on the student magazine and the student newspaper, but he becomes the advertising manager Think about it, there are 6 or 7,000 students that he can reach; this was a real job This is where the hustle starts with Arthur
He is at a huge high school, Erasmus Hall High School
There are 6,000-7,000 students in Brooklyn, in Flatbush
Think about it, there are 6 or 7,000 students that he can reach; this was a real job
This is where the hustle starts with Arthur
But they pretty quickly pivot into commerce
This starts in high school
He’s got more jobs than he can handle so he starts handing them off to the brothers

Creedmoor Psychiatric Hospital

Arthur and his brothers ends up at the Creedmoor Psychiatric Hospital This is a huge asylum, a vast kind of industrial asylum in Queens, New York, a public state mental hospital It was a facility designed for 4,000 beds
It’s interesting because, this is pre- Thorazine
It’s one of the last maximalist phase of big state mental hospitals
People were basically being warehoused for life in these facilities
It’s just prior to the deinstitutionalization that happens in the decades that follow
The brothers get there and they’re shocked by the conditions Arthur, in particular, was trained as a Freudian There’s not a lot of talk therapy happening at a 6,000-bed hospital Lobotomies, electroshock treatment, and things like that were still being done
The brothers are administering electroshock treatments thousands of times It probably became more and more demoralizing for them because they just felt as though, “ how can we as physicians not have developed some more humane way of administering to our patients? ”
At this early point, they develop this theory, that a lot of the afflictions they’re seeing probably have some basis that is fundamentally chemical Therefore there is probably a chemical solution The brothers don’t have anything to do with Thorazine, but when it comes along, they see that as a glimpse of the future they had envisioned
This is a huge asylum, a vast kind of industrial asylum in Queens, New York, a public state mental hospital
It was a facility designed for 4,000 beds
Arthur, in particular, was trained as a Freudian
There’s not a lot of talk therapy happening at a 6,000-bed hospital
Lobotomies, electroshock treatment, and things like that were still being done
It probably became more and more demoralizing for them because they just felt as though, “ how can we as physicians not have developed some more humane way of administering to our patients? ”
Therefore there is probably a chemical solution
The brothers don’t have anything to do with Thorazine, but when it comes along, they see that as a glimpse of the future they had envisioned

The context of the pharmaceutical business when the Sackler brothers come of age

Generally speaking, it was an exciting time in the pharma business
Penicillin was a huge game-change in the Second World War
A lot of these companies that today we think of as big pharma, prior to the Second World War, they didn’t really look like they do now They were producing chemicals, but they weren’t really producing branded drugs in quite the same way And then it becomes this go-go period where they’re all competing, and they’re developing new antibiotics, and they’re coming out with new products every few weeks, and suddenly they need to differentiate themselves Consumers are no longer going to the pharmacy and having the pharmacist mix whatever it is that their doctor has prescribed; they’re going in and requesting drugs by their brand name The Sackler brothers come of age in this exciting, idealistic, whirlwind climate
They were producing chemicals, but they weren’t really producing branded drugs in quite the same way
And then it becomes this go-go period where they’re all competing, and they’re developing new antibiotics, and they’re coming out with new products every few weeks, and suddenly they need to differentiate themselves
Consumers are no longer going to the pharmacy and having the pharmacist mix whatever it is that their doctor has prescribed; they’re going in and requesting drugs by their brand name
The Sackler brothers come of age in this exciting, idealistic, whirlwind climate

Purdue Pharma: origins, early years, and move towards pain management drugs [17:30]

The origins of Purdue Pharma date back to the 19th century It was a little patent medicine company based Christopher Street in Greenwich Village One can go to the building that it once occupied It’s funny that what had once been the humble Purdue Frederick factory is today somebody’s $18 million townhouse
In 1952, Arthur Sackler had already achieved a great deal of financial success Not in the drug business per se, but in pharmaceutical advertising Arthur really makes his name by joining and then taking over a pharmaceutical advertising firm He’s a genius for advertising drugs This is a point where all these drug companies need to figure out ways to differentiate their products and reach doctors and persuade them to prescribe
With some of the money he’s made, Arthur purchases this company, Purdue Frederick He basically gives it to his brothers He’s a stakeholder in the company; he owns a third of it, but he’s a silent partner basically The brothers run the company starting in ’52
Purdue Frederick is a very successful company The brothers get rich But they’re getting rich in a way that even Arthur would probably have sniffed at
Arthur focuses on the marketing of pharmaceuticals His biggest success (he had many successes) is the way he designs the marketing and advertising strategy for the minor tranquilizer, Librium , and then for Valium (both of which Roche develops) Librium becomes the biggest selling drug in the history of the pharmaceutical industry And then it’s surpassed only by Valium And then for years, the two of them are in the top five drugs nationwide
Arthur designed all the advertising and the marketing for that
He devised this interesting compensation scheme where basically he said, “ I’m going to get an escalating series of bonuses, depending on how many pills you sell and there’s no ceiling. ” So he becomes vastly wealthy on the basis of these drugs
Meanwhile, the work of his brothers is less cutting edge They basically license over-the-counter products and then sell them They were really smart about it They had an antiseptic solution, betadine , which is still out there, and they got the rights to that just before the Vietnam War; it had battlefield applications They had a laxative, Senokot , very successful These are the kinds of cash crop products They’re very unglamorous; but they’re staples, over-the-counter stuff; but year in year out, they’re very, very successful
It was a little patent medicine company based Christopher Street in Greenwich Village One can go to the building that it once occupied It’s funny that what had once been the humble Purdue Frederick factory is today somebody’s $18 million townhouse
One can go to the building that it once occupied
It’s funny that what had once been the humble Purdue Frederick factory is today somebody’s $18 million townhouse
Not in the drug business per se, but in pharmaceutical advertising
Arthur really makes his name by joining and then taking over a pharmaceutical advertising firm
He’s a genius for advertising drugs
This is a point where all these drug companies need to figure out ways to differentiate their products and reach doctors and persuade them to prescribe
He basically gives it to his brothers
He’s a stakeholder in the company; he owns a third of it, but he’s a silent partner basically
The brothers run the company starting in ’52
The brothers get rich
But they’re getting rich in a way that even Arthur would probably have sniffed at
His biggest success (he had many successes) is the way he designs the marketing and advertising strategy for the minor tranquilizer, Librium , and then for Valium (both of which Roche develops) Librium becomes the biggest selling drug in the history of the pharmaceutical industry And then it’s surpassed only by Valium And then for years, the two of them are in the top five drugs nationwide
Librium becomes the biggest selling drug in the history of the pharmaceutical industry
And then it’s surpassed only by Valium
And then for years, the two of them are in the top five drugs nationwide
So he becomes vastly wealthy on the basis of these drugs
They basically license over-the-counter products and then sell them
They were really smart about it
They had an antiseptic solution, betadine , which is still out there, and they got the rights to that just before the Vietnam War; it had battlefield applications
They had a laxative, Senokot , very successful These are the kinds of cash crop products They’re very unglamorous; but they’re staples, over-the-counter stuff; but year in year out, they’re very, very successful
These are the kinds of cash crop products
They’re very unglamorous; but they’re staples, over-the-counter stuff; but year in year out, they’re very, very successful

Purdue Pharma’s early interest in pain management [20:15]

“The irony… of the company that would create the opioid boom having a laxative… to address one of the most painful, short-term consequences of opioid use being constipation” – Peter Attia

Patrick agrees and adds that sales reps for Purdue would go out and market OxyContin and laxatives together
It’s only in the late ’70s, early ’80s, that the company starts getting aggressive about investing in R & D developing its own prescription drugs It’s at that point that they move into pain management
It’s at that point that they move into pain management

Why Purdue Pharma remains a private company when others go public

Many of the large pharma companies go public, any inclination why the brothers decided to keep Purdue private?
Patrick speculates that the Sacklers had a real sense that this was a old-world enterprise This was a family-owned, physician-owned business There was a sense that they controlled it and they thought of the people who worked for them as family It’s really only with the advent of OxyContin in the ’90s that it becomes this multi-billion dollar company; up to that point, it was a pretty modest outfit The brothers were very wealthy, but it was a kind of manageable, family firm
He doesn’t know what it would’ve looked like if it went public
However, getting into the later stages, post the introduction of OxyContin, there’s a lot of stuff that happens in this story that would never happen in a public company How do they handle it when they start getting calls saying that the product they sell is killing people? Patrick thinks there probably would have been a different response in a public company Then the really crazy thing is eventually, there is a guilty plea in a federal criminal case in 2007 (he’ll come back to this) He thinks if this had happened at a public company, heads would have rolled There would have been a total change of personnel, a big shakeup on the board At a privately held family company, what happened was pretty much nothing
This was a family-owned, physician-owned business
There was a sense that they controlled it and they thought of the people who worked for them as family
It’s really only with the advent of OxyContin in the ’90s that it becomes this multi-billion dollar company; up to that point, it was a pretty modest outfit
The brothers were very wealthy, but it was a kind of manageable, family firm
How do they handle it when they start getting calls saying that the product they sell is killing people?
Patrick thinks there probably would have been a different response in a public company
Then the really crazy thing is eventually, there is a guilty plea in a federal criminal case in 2007 (he’ll come back to this)
He thinks if this had happened at a public company, heads would have rolled There would have been a total change of personnel, a big shakeup on the board At a privately held family company, what happened was pretty much nothing
There would have been a total change of personnel, a big shakeup on the board
At a privately held family company, what happened was pretty much nothing

Doctors view of pain changes

Dating back to the ’70s, there is a kind of revisionist school of physicians (in the UK and in the US and in other parts of the world) who felt that the medical establishment had been not taking pain seriously enough as a problem, that doctors weren’t treating pain aggressively They felt doctors were treating pain just merely as a symptom and not as a problem in and of itself That there wasn’t enough medical education for physicians in terms of identifying pain and responding to it Going along with this was a sense that many physicians had, that there was a resistance to prescribing opioids out of a fear of addiction A feeling that doctors had been too stingy in prescribing opioids for pain because of concerns about abuse and addiction
They felt doctors were treating pain just merely as a symptom and not as a problem in and of itself
That there wasn’t enough medical education for physicians in terms of identifying pain and responding to it
Going along with this was a sense that many physicians had, that there was a resistance to prescribing opioids out of a fear of addiction A feeling that doctors had been too stingy in prescribing opioids for pain because of concerns about abuse and addiction
A feeling that doctors had been too stingy in prescribing opioids for pain because of concerns about abuse and addiction

MS Contin, the precursor to OxyContin [23:00]

This is the context that the drug MS Contin is developed It’s a drug for cancer pain It’s basically just morphine
The real innovation was the contin part; contin is short for continuous It’s essentially just the coating on the pill The idea is that this will regulate the flow of the drug into the bloodstream over the course of hours
MS Contin was developed in the UK and then rolled out in the US It was a groundbreaking drug in its way; very successful for the company Patrick doesn’t remember exactly what it was generating in terms of revenue at its height, but $300 or $400 million a year, which was a lot for Purdue at the time
The family was proud of this drug; there was a sense that they were doing a good thing They were relieving terrible pain for people suffering from cancer They were doing very well financially In this world of doctors who were thinking about pain and wanting to kind of reevaluate the way in which pain is treated, they were heroes
There was an interesting, and not necessarily cynical confluence of interests in which Purdue starts sponsoring academic conferences on the treatment of pain and medical conferences and seminars
They’re sort of out there with an obvious commercial interest, but also with a sense that they are part of a revolution, thinking “ we’re going to revolutionize the way in which pain is treated. ”
It’s a drug for cancer pain
It’s basically just morphine
It’s essentially just the coating on the pill
The idea is that this will regulate the flow of the drug into the bloodstream over the course of hours
It was a groundbreaking drug in its way; very successful for the company
Patrick doesn’t remember exactly what it was generating in terms of revenue at its height, but $300 or $400 million a year, which was a lot for Purdue at the time
They were relieving terrible pain for people suffering from cancer
They were doing very well financially
In this world of doctors who were thinking about pain and wanting to kind of reevaluate the way in which pain is treated, they were heroes

The development of OxyContin: its conception, marketing, and the controversy around the FDA approval process [25:30]

Peter notes that in some sense OxyContin is an obvious leap because if MS Contin is simply morphine sulfate formulated in a continuous fashion, there are other narcotics out there Percocet already existed; it was simply hydrocodone with Acetaminophen Hydrocodone existed by itself in a non-time-release format So was their great innovation basically saying, we’re just going to make a time-release version of hydrocodone, just as it had been done with morphine?
Percocet already existed; it was simply hydrocodone with Acetaminophen
Hydrocodone existed by itself in a non-time-release format
So was their great innovation basically saying, we’re just going to make a time-release version of hydrocodone, just as it had been done with morphine?

Patents and profitability

When Patrick began researching this topic he was really startled to discover the importance of the life cycle of a patent to a drug company He notes, “ I don’t think I fully appreciated the degree to which it is the sun and the stars and it’s everything ” There were so many points in the course of his reporting for this story where there’d be some sort of mystery about motivation, a weird thing they did, and he couldn’t figure out why It always turned out to be something having to do with a patent
The pediatric indication is a good example At a point where OxyContin was hugely controversial already and causing all kinds of problems, they applied for the pediatric indication for the drug It turned out it was because they thought they would get an additional six months of patent exclusivity if they got it
In the case of MS Contin, the patent is running out at a certain point, and they realized that it’s going to decimate their profits They just start talking about, hey, what else could we put with the contin system? The family dynamics here are a little humorous; according to Kathy Sackler (who’s one of the second generation Sacklers who was involved in the company and is a medical doctor), she has dinner with Richard Sackler (her cousin and kind of rival within the company at a certain point) and she suggests, what about oxycodone? And according to her, Richard didn’t know what oxycodone was and she had to explain it
He notes, “ I don’t think I fully appreciated the degree to which it is the sun and the stars and it’s everything ”
There were so many points in the course of his reporting for this story where there’d be some sort of mystery about motivation, a weird thing they did, and he couldn’t figure out why It always turned out to be something having to do with a patent
It always turned out to be something having to do with a patent
At a point where OxyContin was hugely controversial already and causing all kinds of problems, they applied for the pediatric indication for the drug
It turned out it was because they thought they would get an additional six months of patent exclusivity if they got it
They just start talking about, hey, what else could we put with the contin system?
The family dynamics here are a little humorous; according to Kathy Sackler (who’s one of the second generation Sacklers who was involved in the company and is a medical doctor), she has dinner with Richard Sackler (her cousin and kind of rival within the company at a certain point) and she suggests, what about oxycodone? And according to her, Richard didn’t know what oxycodone was and she had to explain it
And according to her, Richard didn’t know what oxycodone was and she had to explain it

Marketing to increase drug sales

Oxycodone stronger than both hydrocodone and Morphine
Patrick notes what’s interesting about oxycodone is when the company makes their decision to use oxycodone to develop OxyContin, there are these conversations that happen and they happen over email, Patrick has emails where these senior executives at the company and Richard Sackler are talking about the market, and the idea that MS Contin was a drug for cancer pain, and the stigma associated with morphine This notion that if you’re a regular person and not a doctor, and your doctor tells you that your mother’s going on morphine, that means your mother is going to die What they realize is that oxycodone didn’t have those same associations, even though it’s stronger than morphine.
They did focus groups about oxycodone , Percocet , and Percodan ; and that was the primary way in which physicians were encountering those drugs And when they’re cut with aspirin or acetaminophen, it’s a relatively small dose, there’s only so much one can take What they noticed in these focus groups is that physicians had a sort of a sense of oxycodone as more benign, less threatening, there was less stigma, but also they saw it as weaker
There are these incredible emails where they say, well, listen, there’s only so many people who have cancer pain, “ we did great with our cancer drug, but there’s a much bigger market out there of people suffering not just from severe pain, but moderate pain, chronic pain, back pain, sports injuries ” The marketing of oxycodone ended up creating the need for this drug
The first third of Patrick’s book is devoted to Arthur Sackler in those early years; he dies in ‘87 before the introduction of OxyContin
Patrick thinks there are all of these things that happen earlier that are kind of the seeds for what comes later
So the analogy he always thinks of is Thorazine , which the original Sackler brothers see in action; and Thorazine is a major tranquilizer for people who are psychotic It emptied out the asylums pretty quickly; it was a real game-changer; but there’s only so many people who actually require that kind of heavy-duty solution Arthur Sackler made his fortune on the minor tranquilizers, Librium and Valium And who among us doesn’t feel a little stressed at the end of the day; who couldn’t benefit from something to make them relax a little bit This is was what turned Librium and Valium into these huge blockbusters
It’s kind of a similar thing here where there’s this sense that MS Contin is a drug for this subset of people who are experiencing terrible cancer pain There’s a much bigger community of people who have moderate pain, but the weirdness of it is that they then take a drug that is stronger, not weaker and market it that way
These emails show the way in which these executives say “ in our focus groups, doctors erroneously think that oxycodone is weaker than morphine. Let’s not do anything to make them realize that they’re wrong about the product that we’re selling them, because if we did, it could constrain our market. ”
Patrick has emails where these senior executives at the company and Richard Sackler are talking about the market, and the idea that MS Contin was a drug for cancer pain, and the stigma associated with morphine
This notion that if you’re a regular person and not a doctor, and your doctor tells you that your mother’s going on morphine, that means your mother is going to die What they realize is that oxycodone didn’t have those same associations, even though it’s stronger than morphine.
What they realize is that oxycodone didn’t have those same associations, even though it’s stronger than morphine.
And when they’re cut with aspirin or acetaminophen, it’s a relatively small dose, there’s only so much one can take
What they noticed in these focus groups is that physicians had a sort of a sense of oxycodone as more benign, less threatening, there was less stigma, but also they saw it as weaker
The marketing of oxycodone ended up creating the need for this drug
It emptied out the asylums pretty quickly; it was a real game-changer; but there’s only so many people who actually require that kind of heavy-duty solution
Arthur Sackler made his fortune on the minor tranquilizers, Librium and Valium And who among us doesn’t feel a little stressed at the end of the day; who couldn’t benefit from something to make them relax a little bit This is was what turned Librium and Valium into these huge blockbusters
And who among us doesn’t feel a little stressed at the end of the day; who couldn’t benefit from something to make them relax a little bit
This is was what turned Librium and Valium into these huge blockbusters
There’s a much bigger community of people who have moderate pain, but the weirdness of it is that they then take a drug that is stronger, not weaker and market it that way

FDA approval

There’s a guy named Curtis Wright, who was the medical examiner at FDA who was kind of the grand inquisitor; he was the one they had to satisfy in order to get the drug approved He also was the one they had to satisfy in order to get the marketing claims
Richard Sackler, the second generation Sackler is probably the, the most intimately acquainted with or involved with OxyContin
There’s a point where he talks about how the package insert in a bottle of pills is our most potent selling instrument Patrick finds this strange, because for the average consumer, the dense wording of the package insert, the fine print, it feels like something that doctors read; it doesn’t feel like marketing For the drug company, it’s all about the indication It’s all about the claims they can make for what kinds of ailments this medication might alleviate
He also was the one they had to satisfy in order to get the marketing claims
Patrick finds this strange, because for the average consumer, the dense wording of the package insert, the fine print, it feels like something that doctors read; it doesn’t feel like marketing
For the drug company, it’s all about the indication It’s all about the claims they can make for what kinds of ailments this medication might alleviate
It’s all about the claims they can make for what kinds of ailments this medication might alleviate

Competitive positioning

An extreme example in the case of OxyContin, they didn’t do any tests on the addictiveness of the drug They didn’t do any tests on the abuse liability of the drug
There was a kind of hypothesis that they had at Purdue, which was because of the contin system, there wouldn’t be the kind of peaks and troughs – a sort of wave of euphoria when a big dose of the drug hits the bloodstream, followed by diminution and then withdrawal Instead, it’s this steady regulated, continuous flow Their hypothesis was that because of that, it wouldn’t be addictive and it wouldn’t be subject to abuse That was a competitive advantage vis-a-vis other opioid products that were out there on the market
They didn’t do any tests on the abuse liability of the drug
Instead, it’s this steady regulated, continuous flow
Their hypothesis was that because of that, it wouldn’t be addictive and it wouldn’t be subject to abuse
That was a competitive advantage vis-a-vis other opioid products that were out there on the market

Unusual actions during the FDA approval process

There was a crazy stretch where they start working very closely with Curtis Wright on the approval process; some strange stuff happens
The company sends Curtis Wright a webcam in ‘95 (Patrick doesn’t even think this is in the book)
This is a very early webcam where he can talk directly with folks in Stanford
Curtis Wright starts requesting that they send things, not to his FDA office, but to his house
At a certain point, a team of people from Purdue travel to Maryland and get a hotel room and they spend three days with Curtis Wright, helping him write his reviews of their studies
Peter comments, “ It’s almost impossible to imagine that happening. I’m not saying it didn’t because you’ve got email proof that it happened. I’m just saying from a matter of process, that statement is so difficult to comprehend. How do we put that in perspective? What did other people at the FDA know at this point in time? ”
Patrick got Curtis Wright on the phone but he very quickly hung up; he didn’t want to talk about any of this
Patrick filed a freedom of information act request with the FDA; they dragged their feet in the way that federal bureaucracy’s always do So he sued them in federal court to compel them to turn over documents
He got a New York federal judge to order them to do document production for him, thousands and thousands of pages of documents His first request was for all the emails of Curtis Wright This is a guy who had been investigated by Department of Justice starting in 2002, 2003; this was somebody who was red flagged early by other federal agencies The FDA came back and told me that all of his correspondence and emails have either been lost or destroyed It was a sort of a document retention thing where after a certain number of years, they eliminate stuff Their response was pretty shocking to Patrick
Some of this email has come out, not through the FDA, but through federal investigations of Purdue
There’s an interesting moment where one of the Purdue officials says that he happened to bump into Curtis Wright at a conference As all of this approval stuff’s happening, they talked informally, in a kind of a sidebar way There’s this interesting memo that the Purdue guy sends back to headquarters where he says, “ I got talking with Curtis Wright, it was great. We talked about the whole OxyContin thing. He indicated that he would be open to other such informal exchanges in the future or something to that effect. ” Patrick doesn’t know what this means
Peter notes that a year after leaving the FDA, Curtis Wright becomes employed by Purdue Pharma He asks the question, “ isn’t the only obvious explanation here that there was a quid pro quo, a very clear and direct quid pro quo made between Purdue and Curtis Wright? ”
The former federal prosecutor, longtime federal prosecutor from the Western district of Virginia who prepared the biggest case against Purdue and spent years pouring over millions of pages of documents and looked really hard at Curtis Wright, he told Patrick on the record (and this is a guy who was pretty careful about what he says), “ I think a deal was made. He said, I can’t prove it. Just my opinion. But I think a deal was made. ” Patrick doesn’t even think Purdue had to say, “ hey, make this work for us; and there might be a job for you on the other side ”
So he sued them in federal court to compel them to turn over documents
His first request was for all the emails of Curtis Wright
This is a guy who had been investigated by Department of Justice starting in 2002, 2003; this was somebody who was red flagged early by other federal agencies
The FDA came back and told me that all of his correspondence and emails have either been lost or destroyed It was a sort of a document retention thing where after a certain number of years, they eliminate stuff
Their response was pretty shocking to Patrick
It was a sort of a document retention thing where after a certain number of years, they eliminate stuff
As all of this approval stuff’s happening, they talked informally, in a kind of a sidebar way
There’s this interesting memo that the Purdue guy sends back to headquarters where he says, “ I got talking with Curtis Wright, it was great. We talked about the whole OxyContin thing. He indicated that he would be open to other such informal exchanges in the future or something to that effect. ” Patrick doesn’t know what this means
Patrick doesn’t know what this means
He asks the question, “ isn’t the only obvious explanation here that there was a quid pro quo, a very clear and direct quid pro quo made between Purdue and Curtis Wright? ”
Patrick doesn’t even think Purdue had to say, “ hey, make this work for us; and there might be a job for you on the other side ”

Soft corruption

From a policy point of view, this gets really hard to regulate, right? The FDA is full of overeducated, really smart people who are making government salaries They have the unglamorous task of working on these approvals And on the other side of the table is this huge multi-billion dollar industry where one can make a lot of money and where there’s a great deal of interest in former FDA officials, both in having them come and work at the pharmaceutical firm because it’s useful in a whole bunch of ways
He would argue, there’s probably a great deal of interest in having the FDA officials that you’re talking to know that someday there might be a job for them This is a hard thing because it’s not corruption in an explicit quid pro quo sense It’s not corruption in a way that’s actually all that easy to police What should the FDA do? Have a cooling off period when someone leaves the agency. How long? A year? Three years? At what point do they start losing talent?
The FDA is full of overeducated, really smart people who are making government salaries
They have the unglamorous task of working on these approvals
And on the other side of the table is this huge multi-billion dollar industry where one can make a lot of money and where there’s a great deal of interest in former FDA officials, both in having them come and work at the pharmaceutical firm because it’s useful in a whole bunch of ways
This is a hard thing because it’s not corruption in an explicit quid pro quo sense
It’s not corruption in a way that’s actually all that easy to police What should the FDA do? Have a cooling off period when someone leaves the agency. How long? A year? Three years? At what point do they start losing talent?
What should the FDA do?
Have a cooling off period when someone leaves the agency. How long? A year? Three years? At what point do they start losing talent?
At what point do they start losing talent?

“I don’t mean to suggest for a second that these are easy questions, but I also think there’s what I would call a kind of soft corruption that pervades this whole process.” – Patrick Radden Keefe

This is not unique to Curtis Wright; he’s a very extreme example He continues to work at the FDA for a year after OxyContin is approved; then he goes and works at Purdue for three times his government salary
He continues to work at the FDA for a year after OxyContin is approved; then he goes and works at Purdue for three times his government salary

The odd label on the packaging

To the point about the marketing claims, there’s a line in the original package insert for OxyContin that says the content seal is believed to reduce the abuse liability of the drug This is a weird thing to have in a package insert in general It’s a great marketing claim, but if believed it doesn’t seem very scientific necessarily
No studies were done to back up this claim In this case, it was conjecture They reasoned that because someone taking this drug doesn’t get the high highs and low lows, therefore, it would make it less prone to abuse than other drugs
This is a weird thing to have in a package insert in general
It’s a great marketing claim, but if believed it doesn’t seem very scientific necessarily
In this case, it was conjecture
They reasoned that because someone taking this drug doesn’t get the high highs and low lows, therefore, it would make it less prone to abuse than other drugs

“The real measure of how compromised this line was is that to this day, nobody will admit writing that line.” – Patrick Radden Keefe

Curtis Wright has been asked about this and he said, “ oh yeah, it wasn’t the FDA, it was Purdue pharma ” and the Purdue pharma officials who were there say, “ oh, it wasn’t us, it was Curtis Wright ” Patrick feels that the FDA worked so closely with the drug company, that literally he don’t know where one ends and the other begins
Patrick feels that the FDA worked so closely with the drug company, that literally he don’t know where one ends and the other begins

“There’s a line that ends up in the package insert, claiming that this drug is safer than other alternatives, and nobody can tell you who wrote it” – Patrick Radden Keefe

Early reports of OxyContin addiction and unintended consequences and how Purdue Pharma sidestepped responsibility [40:45]

Timeline from release to reports of addiction

OxyContin become available in ‘96
What are the unintended consequences of this drug? 1) People use this drug who would probably be better served using another drug 2) People taking the drug become addicted and some die
What were the canaries in the coal mine that drew attention to any unintended consequences
The official story is the drug’s released in early ’96 and according to sworn testimony by several senior executives at the company and by Richard Sackler, they had no inkling that there was any kind of a major problem for 4 years
Patrick relates, “ there were four blissful years where they got lots of letters from pain patients saying, you’ve given me my life back ”
In early 2000 the United States attorney for the state of Maine wrote a letter to thousands of physicians saying this drug OxyContin is really dangerous It’s killing people People are overdosing Further, there is a crime problem associated with it
A bit later, the chief medical officer, Paul Goldenheim, the chief medical officer of Purdue Pharma is brought in front of Congress He says the company had no inkling that there was any kind of big problem until this hinge point, which is when this US attorney wrote this letter in 2000 There is one caveat Patrick points out, “ the other thing they say is that they say, oh, we read about it in the press ”
1) People use this drug who would probably be better served using another drug
2) People taking the drug become addicted and some die
It’s killing people
People are overdosing
Further, there is a crime problem associated with it
He says the company had no inkling that there was any kind of big problem until this hinge point, which is when this US attorney wrote this letter in 2000
There is one caveat Patrick points out, “ the other thing they say is that they say, oh, we read about it in the press ”

“For me as a journalist, this was funny because I’ve written about a lot of companies doing bad things, and reporters like to take credit where they can get it. But generally speaking, if a company is doing a bad thing, they don’t find out about it because they read about it in your article. They usually know a long time before the rest of the world does.” – Patrick Radden Keefe

When Patrick dug into this statement, he found documentation to show this was a lie They knew about the problem really early on
They knew about the problem really early on
Emails from the late 1990’s contain all kinds of back and forth about these drugs Very senior people, including Goldenheim emailed about the fact that there’s an abuse problem Pharmacies were getting robbed People talked about the street value of the drug There was a media advisory group that was brought in to do interviews with these senior officials There are literally emails in which some of these senior officials who later claimed that nothing was said, will be emailing about it, and then they’ll say, “s hould we have all this chat on email? It’s maybe not a good idea for us to be having these conversations on email ”
There’s another sort of associated lie that they told, which is that there had never been a problem with MS Contin This was a lie that was told under oath
Patrick found the company had a very clear awareness of the problem
He argues that OxyContin changed the way in which these drugs are prescribed as a category of drugs They had one of the biggest marketing forces ever They sent out hundreds of sales reps (700) to fan out across the country and meet with thousands and thousands of physicians That was how they kind of got the message of OxyContin out there
Very senior people, including Goldenheim emailed about the fact that there’s an abuse problem
Pharmacies were getting robbed
People talked about the street value of the drug
There was a media advisory group that was brought in to do interviews with these senior officials
There are literally emails in which some of these senior officials who later claimed that nothing was said, will be emailing about it, and then they’ll say, “s hould we have all this chat on email? It’s maybe not a good idea for us to be having these conversations on email ”
This was a lie that was told under oath
They had one of the biggest marketing forces ever
They sent out hundreds of sales reps (700) to fan out across the country and meet with thousands and thousands of physicians That was how they kind of got the message of OxyContin out there
That was how they kind of got the message of OxyContin out there

Canaries in the coal mine

A story Patrick tells in his book is about a guy named Steve May, who was a Purdue sales rep in West Virginia in’99 So this is before, according to Goldenheim they didn’t know anything at this point. In ’99 Steve May had this one doctor, a big prescriber They would call them whales, to use the vernacular of a Vegas casino for a big gambler As a sales rep, this was great for your bonus to have a big prescriber So Steve May had this whale; he went to call on her, which he would do from time to time; and she was upset when he showed up He asked her what the problem was; and she said she had a young relative, a young girl who had just died of an OxyContin overdose All the reps write up these encounters in notes and send them back to headquarters
So this is before, according to Goldenheim they didn’t know anything at this point.
In ’99 Steve May had this one doctor, a big prescriber They would call them whales, to use the vernacular of a Vegas casino for a big gambler As a sales rep, this was great for your bonus to have a big prescriber So Steve May had this whale; he went to call on her, which he would do from time to time; and she was upset when he showed up He asked her what the problem was; and she said she had a young relative, a young girl who had just died of an OxyContin overdose
All the reps write up these encounters in notes and send them back to headquarters
They would call them whales, to use the vernacular of a Vegas casino for a big gambler
As a sales rep, this was great for your bonus to have a big prescriber
So Steve May had this whale; he went to call on her, which he would do from time to time; and she was upset when he showed up He asked her what the problem was; and she said she had a young relative, a young girl who had just died of an OxyContin overdose
He asked her what the problem was; and she said she had a young relative, a young girl who had just died of an OxyContin overdose

“So I think what I was able to substantiate in the book at some length is that it’s clear really early on there’s a problem… from as early as ’97. So that’s just a year after the drug is released” – Patrick Radden Keefe

These discussions are not just happening at low levels; they’re happening at high levels
Patrick thinks what happens in 2000 is it just becomes impossible for them to deny it anymore

Company spin to avoid responsibility

The spin they put on it was a bunch of things Peter summarized the company spin as, “ We’ve created a miracle breakthrough product that helps millions of people, but there are these derelicts who abused this product and are jeopardizing it for everybody else. We really need to ramp up the enforcement of those people ”
Patrick explains the stance of Purdue Pharma They suggest there’s nothing intrinsically dangerous about the drug The level of denial here is pretty impressive The Sacklers even today argue that instances of Iatrogenic addiction to OxyContin is rare Where it’s prescribed to a patient by a doctor for a legitimate condition, and the patient takes it as instructed by the physician and then becomes addicted
Peter summarized the company spin as, “ We’ve created a miracle breakthrough product that helps millions of people, but there are these derelicts who abused this product and are jeopardizing it for everybody else. We really need to ramp up the enforcement of those people ”
They suggest there’s nothing intrinsically dangerous about the drug
The level of denial here is pretty impressive
The Sacklers even today argue that instances of Iatrogenic addiction to OxyContin is rare Where it’s prescribed to a patient by a doctor for a legitimate condition, and the patient takes it as instructed by the physician and then becomes addicted
Where it’s prescribed to a patient by a doctor for a legitimate condition, and the patient takes it as instructed by the physician and then becomes addicted

The many paths to addiction and abuse of OxyContin and the ensuing downfall of Purdue Pharma [47:15]

Divide users into 3 buckets

Peter asks about patients who are prescribed OxyContin; to be overly simplistic, let’s say there are 3 buckets in which a patient comes across this drug (other than terminally ill cancer patients): 1) A patient recovering from surgery; they get a legitimate prescription to get them through the perioperative period 2) The sham doctor who’s prescribing this stuff from one state when you’re in another state doing it online or running basically the revolving door clinic The patient will get the prescription and go out the door, provided they fill it at a pharmacy, a couple of hundred miles away 3) Illicit acquisition of OxyContin through a stolen channel What is the relative distribution of patients among these 3 paths? Patrick notes it’s impossible to parse this out It also fluctuates a lot over time He has found a few data points
Patrick found 2 examples (numbered below) in his research related to this distribution of patients in these 3 buckets are some of the more shocking things he discovered in his research It’s hard though because it is complex
1) A patient recovering from surgery; they get a legitimate prescription to get them through the perioperative period
2) The sham doctor who’s prescribing this stuff from one state when you’re in another state doing it online or running basically the revolving door clinic The patient will get the prescription and go out the door, provided they fill it at a pharmacy, a couple of hundred miles away
3) Illicit acquisition of OxyContin through a stolen channel
What is the relative distribution of patients among these 3 paths? Patrick notes it’s impossible to parse this out It also fluctuates a lot over time He has found a few data points
The patient will get the prescription and go out the door, provided they fill it at a pharmacy, a couple of hundred miles away
Patrick notes it’s impossible to parse this out
It also fluctuates a lot over time
He has found a few data points
It’s hard though because it is complex

“ And so sometimes I think from the cheap seats, it’s hard to appreciate the gravity of this.” – Patrick Radden Keefe

Purdue sells OxyContin; they release it in ’96
Right away people realize that that content seal can be overridden just by crushing the pills People can chew the pill, grind the pill, dissolve it in water after it has been ground and shoot it intravenously There’s actually a warning on the bottle advising not to crush the pills because if this could lead to a potentially toxic dose of oxycodone In a weird way, this functions as a kind of inadvertent, how to Patrick thinks this is significant for maybe for all three of the buckets Peter mentioned because there are people who are just opportunistic drug users looking to get high
Patrick interviewed a lot of people who said that heroin was scary Heroin had to be bought on the street One had to shoot it with a needle These were people looking to get high
1) OxyContin was a party drug in high school, but there was something reassuring about the fact that it had been approved by the FDA Even if they bought it from a dealer, at some point there was a doctor writing a prescription
2) There are also people who are prescribed the drug by a doctor, and it doesn’t work for as long as they think it will, or they find themselves just kind of in its grip, they want more Some of those people actually convert to the immediate release thing What they find is they don’t want to wait, and so they’ll end up chewing the pills because it relieves their pain faster; this is what they say
So there are different ways of getting addicted
People can chew the pill, grind the pill, dissolve it in water after it has been ground and shoot it intravenously
There’s actually a warning on the bottle advising not to crush the pills because if this could lead to a potentially toxic dose of oxycodone In a weird way, this functions as a kind of inadvertent, how to Patrick thinks this is significant for maybe for all three of the buckets Peter mentioned because there are people who are just opportunistic drug users looking to get high
In a weird way, this functions as a kind of inadvertent, how to
Patrick thinks this is significant for maybe for all three of the buckets Peter mentioned because there are people who are just opportunistic drug users looking to get high
Heroin had to be bought on the street
One had to shoot it with a needle
These were people looking to get high
Even if they bought it from a dealer, at some point there was a doctor writing a prescription
Some of those people actually convert to the immediate release thing
What they find is they don’t want to wait, and so they’ll end up chewing the pills because it relieves their pain faster; this is what they say

Maximizing profits at Purdue

In 2010, Purdue rolls out a reformulated version of OxyContin that they’ve worked on for years It can’t be crushed It’s like a gummy bear; if one tries to break it up, it just kind of goes chewy and gummy There’s an interesting backstory here, questions about why it took so long to roll this out There’s an interesting aspect of the timing, the original patent on OxyContin was about to run out So just in the nick of time, they have this line extension basically in the form of the reformulated drug
Peter skeptically notes, “ at the time they even basically declare that their old formulation is probably unsafe, which is really a great dig at the competition, which is as we’re about to roll this thing off its patent life, we want to make sure that nobody else uses it either as we reignite a new patent on a new drug, which is infinitely safer in the presence of our old dangerous drug ”
Patrick agrees and explains there are emails going back years and years and years talking about how, if they came up with a kind of abuse-proof/tamper-proof formulation that would function as a line extension This was the reason they were doing it, primarily was to extend the patent life
It can’t be crushed
It’s like a gummy bear; if one tries to break it up, it just kind of goes chewy and gummy
There’s an interesting backstory here, questions about why it took so long to roll this out There’s an interesting aspect of the timing, the original patent on OxyContin was about to run out So just in the nick of time, they have this line extension basically in the form of the reformulated drug
There’s an interesting aspect of the timing, the original patent on OxyContin was about to run out
So just in the nick of time, they have this line extension basically in the form of the reformulated drug
This was the reason they were doing it, primarily was to extend the patent life

“The surpassing cynicism of the idea that having at that point 14 years said, oh, it’s perfectly safe… the original formulation. They develop a new formulation, and then they turn around and say, well, we wouldn’t want to see any generic versions of the original formulation because in fact it’s not so safe after all, it’s amazing.” – Patrick Radden Keefe

This worked; the FDA was obliged to extend their patent
In 2010 the reformulated version is rolled out, and the old pills, they kind of disappear from the shelves and the new ones take their place
He found an internal study that showed when this happened for the 80 milligram pills in 2010 sales nationwide fell 25% This statistic that really blows Patrick’s mind The 80 mg pills were the biggest and most profitable pills on the market They were also the most popular on the black market
He can’t tell you proportionately who’s in what bucket What he can tell you is that up to 2010, I think it’s safe to intuit 25% of the sales of 80 milligram OxyContin were going to people who were abusing those pills in one way or another This is astonishing to Patrick, “ because I mean, that’s a non-trivial part of the company’s profits. So on the one hand it’s they don’t want their patients, their customers to die. On the other hand, there is a sense in which even as they were decrying the black market, the black market was helping to pay the bills at the company. ”
It’s impossible to know how many people left bucket 1 (who were originally prescribed OxyContin legitimately for non-cancer pain by a caring, understanding physician) and went to bucket 2 or 3 as their appetite for this drug grew versus how many people came de novo to bucket 2 or 3 simply seeking to get high
This statistic that really blows Patrick’s mind
The 80 mg pills were the biggest and most profitable pills on the market They were also the most popular on the black market
They were also the most popular on the black market
What he can tell you is that up to 2010, I think it’s safe to intuit 25% of the sales of 80 milligram OxyContin were going to people who were abusing those pills in one way or another
This is astonishing to Patrick, “ because I mean, that’s a non-trivial part of the company’s profits. So on the one hand it’s they don’t want their patients, their customers to die. On the other hand, there is a sense in which even as they were decrying the black market, the black market was helping to pay the bills at the company. ”

Overdose deaths and opioid use disorders

Patrick notes, “when you look at toxicity reports on people who die, people who overdose, it’s often not just OxyContin in the bloodstream, right? It’s often mixed with other things”
So there’s this whole exercise of parsing, moral and legal parsing that Purdue Pharma does that is amazing

“At a certain point, so many people have died from your product. It’s this kind of incredible symphony of rationalization that happens.” – Patrick Radden Keefe

Purdue pharma is now in bankruptcy, and in the context of the bankruptcy, there are many, many, many creditors who have a claim that they’d like to exert against what’s left of the company One of them is United Health United Health had this fascinating filing where they were talking about the idea that they should have a piece of the pie such as it is He will leave aside for a second, whether a big insurer should be there in line along with all these people whose lives have been ruined by the drug
What was interesting is that United Health said they ran a study over 7 or 8 years and looked at people who had United Health plans and who were prescribed OxyContin or another Purdue opioid, and subsequently diagnosed with an opioid use disorder (OUD); they said the number was in the hundreds of thousands Patrick thinks that would actually be a kind of a smaller subset because there needed to be a diagnosis of an OUD He doesn’t know what percentage of people initially given a prescription later had a diagnosis of an OUD This would be interesting but it was not revealed in the filing to the bankruptcy court
One of them is United Health
United Health had this fascinating filing where they were talking about the idea that they should have a piece of the pie such as it is He will leave aside for a second, whether a big insurer should be there in line along with all these people whose lives have been ruined by the drug
He will leave aside for a second, whether a big insurer should be there in line along with all these people whose lives have been ruined by the drug
Patrick thinks that would actually be a kind of a smaller subset because there needed to be a diagnosis of an OUD
He doesn’t know what percentage of people initially given a prescription later had a diagnosis of an OUD This would be interesting but it was not revealed in the filing to the bankruptcy court
This would be interesting but it was not revealed in the filing to the bankruptcy court

Peter’s personal experience with OxyContin [57:00]

Back injury and complications from a botched surgery

Peter relates a personal history with OxyContin
When he was in his last year of medical school, a little over 20 years ago, he had a really bad back injury
For 2 weeks or so he just ignored it, but he pain grew more and more debilitating
He remembers doing a rotation and he couldn’t even sleep He had to get the residents to inject Toradol into his thighs just to allow him to be able to sleep for a while
Finally he got a MRI It revealed a really bad herniation in his lower back And also a 5 cm fragment of disc had broken off on the left side, and it floated down the canal and it was sitting on the S one nerve root, which is what was causing this indescribable amount of pain
He underwent surgery the next day, but it didn’t go well for a number of reasons The surgeon operated on the wrong side He awoke from surgery in terrible pain He also had a new complication on the other side
This resulted in a number of followup procedures initially aimed at correcting the first problem
Before he knew it, even once the structural problem had been fixed, the pain was so bad that he finally relented and agreed to take pain medicine He had been horribly petrified of taking anything beyond NSAIDs
This is the year 2000; the first prescription he gets is 20 milligrams of OxyContin to be taken, probably twice a day Within 4 months he was taking almost 400 mg a day For the listener who doesn’t know what that means in context, that would be enough to kill an entire family of drug naive people 400 milligrams would kill Mom, Dad, Susie, Bobby, Sally; they would just stopped breathing So it didn’t take long for Peter to go from 40 milligrams a day to 400 milligrams a day And this was all prescribed by a legitimate doctor who was not at all an expert in pain management
He had to get the residents to inject Toradol into his thighs just to allow him to be able to sleep for a while
It revealed a really bad herniation in his lower back
And also a 5 cm fragment of disc had broken off on the left side, and it floated down the canal and it was sitting on the S one nerve root, which is what was causing this indescribable amount of pain
The surgeon operated on the wrong side
He awoke from surgery in terrible pain
He also had a new complication on the other side
He had been horribly petrified of taking anything beyond NSAIDs
Within 4 months he was taking almost 400 mg a day For the listener who doesn’t know what that means in context, that would be enough to kill an entire family of drug naive people 400 milligrams would kill Mom, Dad, Susie, Bobby, Sally; they would just stopped breathing So it didn’t take long for Peter to go from 40 milligrams a day to 400 milligrams a day And this was all prescribed by a legitimate doctor who was not at all an expert in pain management
For the listener who doesn’t know what that means in context, that would be enough to kill an entire family of drug naive people
400 milligrams would kill Mom, Dad, Susie, Bobby, Sally; they would just stopped breathing
So it didn’t take long for Peter to go from 40 milligrams a day to 400 milligrams a day
And this was all prescribed by a legitimate doctor who was not at all an expert in pain management

“No one was monitoring how much of this drug I needed. The dose just kept going up and up and up.” – Peter Attia

Quitting OxyContin

Peter feels very fortunate to have been dating an anesthesiology resident She was about three or four years older than him; probably in her last year of anesthesia She herself was actually interested in pain management She would go on to do a fellowship in pain management She was a bit troubled by how much of this drug that he was on This got Peter thinking, “ how the hell did I get here? Because it happened so quickly. One minute you’re like I never, ever, ever want to take one of these drugs; and then the next minute, you’re basically in a constant haze. ”
There was no moment when Peter wasn’t high
The turning point came when he couldn’t differentiate pain relief and being high
At the time, he was convinced that he would never walk again; it was a 1-year recovery process; but he couldn’t walk in the first 3 months It shattered all of his dreams of becoming a surgeon, let alone an active, healthy person He was taking the drug just as much to blunt that grief as he was to blunt the pain
He finally decided he didn’t want to take the drug anymore He never imagined he would overdose It never crossed his mind that he could get ot a point where he would stop breathing
He told his girlfriend, “ I’m going to stop this cold turkey. ” She replied, “ You absolutely can’t do that. The withdrawal from this will kill you just as much as this drug will kill you. You need to be on nortriptyline , morphine . ” She rattled off all the drugs he would need to take to taper off But he was a stubborn kid and he just stopped cold turkey
She was about three or four years older than him; probably in her last year of anesthesia
She herself was actually interested in pain management
She would go on to do a fellowship in pain management
She was a bit troubled by how much of this drug that he was on
This got Peter thinking, “ how the hell did I get here? Because it happened so quickly. One minute you’re like I never, ever, ever want to take one of these drugs; and then the next minute, you’re basically in a constant haze. ”
It shattered all of his dreams of becoming a surgeon, let alone an active, healthy person
He was taking the drug just as much to blunt that grief as he was to blunt the pain
He never imagined he would overdose
It never crossed his mind that he could get ot a point where he would stop breathing
She replied, “ You absolutely can’t do that. The withdrawal from this will kill you just as much as this drug will kill you. You need to be on nortriptyline , morphine . ” She rattled off all the drugs he would need to take to taper off
But he was a stubborn kid and he just stopped cold turkey
She rattled off all the drugs he would need to take to taper off

“And the next three weeks of my life would be about the most miserable three weeks of my existence” – Peter Attia

What Peter learned about addiction

What he has learned since suggests he is biologically lucky
He truly believes that the neuro-transmitters in his brain are not wired the way that someone who, in that exact situation, would have become a lifelong addict He’s lucky because that chemical didn’t put a hook in him the way it would in others He had become physiologically dependent on it, and that’s why he went through withdrawal, just as anybody would
He feels very lucky that he managed to escape this drug He’s still afraid of the drug after the fact
Only 7 years later, when he had a really, really bad dental issue would he ever touch another Percocet in his life Which of course, is a fraction of the drug He remembers being really worried about what was going to happen Worried about the risk of it escalating into massive use Fortunately it didn’t; he only needed Percocet for a week until he had a tooth extracted Then he simply stopped taking it and was fine
This experience gave him more empathy with people who become addicted
Patrick has talked to so many people whose lives have been upended by this drug and other opioids It’s often like there’s a kind of undertow; there’s just this sense for them that they’re suddenly in the grip of something
He’s lucky because that chemical didn’t put a hook in him the way it would in others
He had become physiologically dependent on it, and that’s why he went through withdrawal, just as anybody would
He’s still afraid of the drug after the fact
Which of course, is a fraction of the drug
He remembers being really worried about what was going to happen Worried about the risk of it escalating into massive use
Fortunately it didn’t; he only needed Percocet for a week until he had a tooth extracted Then he simply stopped taking it and was fine
Worried about the risk of it escalating into massive use
Then he simply stopped taking it and was fine
It’s often like there’s a kind of undertow; there’s just this sense for them that they’re suddenly in the grip of something

“You managed to get out of the grip, but it sounds like… you were titrating up so fast.” – Patrick Radden Keefe

Peter agrees, “ that upward speed was unbelievable, Patrick. Unbelievable, how quickly a tolerance developed ”

“By the way, it’s total bullshit to say you don’t get high from a time release drug” – Peter Attia

He doesn’t know what it’s like to take heroin, but this is blunt; he thinks it would compare to heroin
There is an absolute blast-off high that came from those mega doses of OxyContin

Doctors who prescribe OxyContin

What’s fascinating to Patrick about Peter’s story is the doctor, that the surgeon writes this prescription Purdue and other drug companies argued from the beginning that doctors don’t know enough about pain management, they haven’t gotten the training There was some truth to that The weirdness of it is, they then rush into the vacuum and they say, “ We’ll provide that training. We’ll do that education. ”
The catchphrase for OxyContin early on was that “ it’s the drug to start with and to stay with ” This first part of this says “ This isn’t some nuclear solution you keep on the top shelf, or you would try other courses of therapy and only when those fail, do you resort to it “; it’s the first thing that should be administered Then it’s the one to stay with, meaning, one can just keep taking it for chronic pain conditions year in, year out, even if one has to keep titrating up
It was a core belief at the company, Richard Sackler felt very strongly about this, that there was no ceiling effect with OxyContin Patients could keep taking greater and greater doses, which they would need as tolerance develops This message is delivered by pharmaceutical reps, who are meeting with doctors like Peter’s surgeon, and who are heavily incentivized to get those docs to titrate up
Profits and even the bonuses for the pharma reps are all based on volume of the drug that’s sold and prescribed
Hearing Peter’s anecdote, Patrick sees the other side, this sort of perfect storm of scenarios where, when Peter’s discussing with his girlfriend, “ Do I go cold turkey? Do I taper off? Should I be taking morphine? ” Because the guy who prescribed Peter the drug, probably doesn’t know how to explain to people how to get them off
This is a crazy situation in which there are a generation of doctors who learn how to on-ramp their patients with these drugs and never learn how to off-ramp them Further, they don’t necessarily have any interest or inclination to do so Patrick has talked to people who’ve had these experiences, they’ll say, “ I went back to the surgeon who wrote me the original script and said I’m having problems here ” Then the doctor replied, “ Whoa, whoa, whoa. I’m not an addiction specialist ” When he looks at all those circumstances and extrapolates from that story Peter just told, it’s not surprising to him to think that there are many, many, many people who had a similar situation and ended up in very dire straits
Purdue and other drug companies argued from the beginning that doctors don’t know enough about pain management, they haven’t gotten the training There was some truth to that
The weirdness of it is, they then rush into the vacuum and they say, “ We’ll provide that training. We’ll do that education. ”
There was some truth to that
This first part of this says “ This isn’t some nuclear solution you keep on the top shelf, or you would try other courses of therapy and only when those fail, do you resort to it “; it’s the first thing that should be administered
Then it’s the one to stay with, meaning, one can just keep taking it for chronic pain conditions year in, year out, even if one has to keep titrating up
Patients could keep taking greater and greater doses, which they would need as tolerance develops
This message is delivered by pharmaceutical reps, who are meeting with doctors like Peter’s surgeon, and who are heavily incentivized to get those docs to titrate up
Because the guy who prescribed Peter the drug, probably doesn’t know how to explain to people how to get them off
Further, they don’t necessarily have any interest or inclination to do so
Patrick has talked to people who’ve had these experiences, they’ll say, “ I went back to the surgeon who wrote me the original script and said I’m having problems here ” Then the doctor replied, “ Whoa, whoa, whoa. I’m not an addiction specialist ” When he looks at all those circumstances and extrapolates from that story Peter just told, it’s not surprising to him to think that there are many, many, many people who had a similar situation and ended up in very dire straits
Then the doctor replied, “ Whoa, whoa, whoa. I’m not an addiction specialist ”
When he looks at all those circumstances and extrapolates from that story Peter just told, it’s not surprising to him to think that there are many, many, many people who had a similar situation and ended up in very dire straits

Help Peter received to treat his pain and stay off OxyContin

Peter remembers another reason why he was very fortunate to have a girlfriend who was an anesthesiologist and also a year away from doing a pain fellowship; she got him in to see a pain expert at Stanford, Sean Mackey He thinks this guy really saved him It was one thing to quit OxyContin cold turkey, but he still had pain
He thinks this guy really saved him
It was one thing to quit OxyContin cold turkey, but he still had pain

“Getting off the drug was one problem, but addressing the pain was another” – Peter Attia

To begin with he did a lot of injections
He cooled off things that flared up using a drug called Neurontin It’s not addictive; it’s incredibly benign It is sedating, so that’s a drawback to dealing with neuropathic pain
He also used Vioxx , a very strong NSAID This drug saved him
These drugs allowed him to break the cycle of pain and do enough PT, such that a year from when that whole thing began, he was actually in his surgical residency and free of all pain medication Free of Neurontin and free of Vioxx
His story could have had a different ending without these people in his life
After going off OxyContin cold turkey, he could have gone back to the drug because there was no other alternative to treat the pain
It’s not addictive; it’s incredibly benign
It is sedating, so that’s a drawback to dealing with neuropathic pain
This drug saved him
Free of Neurontin and free of Vioxx

Pain—the “fifth vital sign,” how doctors are trained in pain management, and the influence of money [1:08:00]

What surgeons learn about pain management in residency

Peter is amazed at how ignorant he and other surgical residents were of pain management

“There was absolutely no teaching of this subject matter” – Peter Attia

Something very simple he learned, studies had demonstrated that before the surgeon makes an incision on a patient, if they inject Marcaineat the incision site and then immediately following surgery, you put the patient on a pretty aggressive dose of inseds. Many patients can actually avoid narcotics post-operatively for the incisional pain The incisional pain is the dominant source of pain Marcaine is a sodium channel blocker, like Novocaine that the dentist would use Marcaine long acting and similar to lidocaine , which is short acting Peter remembers thinking, “ Why aren’t we doing this with every patient? ”
The incisional pain is the dominant source of pain
Marcaine is a sodium channel blocker, like Novocaine that the dentist would use
Marcaine long acting and similar to lidocaine , which is short acting
Peter remembers thinking, “ Why aren’t we doing this with every patient? ”

The pressure on doctors to save time

He got into an argument with one of the attendings because I was about to do an operation and I went to do this; the attending was complaining that it was going to take 5 minutes and they didn’t have time for that Peter remembers thinking, “ Really? We don’t have five minutes? ” It was shocking
Patrick remarks that from the outside, he thinks that one of the ingredients that created the opioid crisis is actually that idea of, “ We don’t want to waste five minutes. We need to get our patients in and out. Time is money. ”
He’s interviewed doctors who talk about ‘how they felt duped,’ how, when the Purdue sales reps started flogging OxyContin and when doctors encounter patients who were in pain, they want to relieve that pain Suddenly there is this medical innovation, which they are told is like a panacea; it can relieve that pain and has virtually no side effects and people can take it forever, and there’s no dosage ceiling He’s talked to people who’ve said this was a siren song they were all too ready to listen to because it filled a need in their therapeutic arsenal Of course it ended up being more complicated
When Patrick thinks about how American medicine is structured, the idea that doctors have a patient who’s in pain, and they say, “ I’m going to write you a prescription for 20 milligrams of OxyContin. ” Then the patient will be on their way and they never have to see them again The doctor doesn’t give any thought to how this is working out for them two weeks from now or two months from now or two years from now It’s that notion that ‘five minutes is money.’ That five minutes is five minutes, they’re not spending with the next patient; it’s a longer line in the waiting room He thinks those kinds of structural considerations are part of what allowed Purdue and other opioid makers to snow the medical establishment as effectively as they did
Take a look at the prescribing levels for these drugs; with the introduction of OxyContin, they just suddenly start climbing in this really dramatic way He would have thought there would have been more skepticism, that it would have been slower growth He does think there was a sense in which it sort of filled a number of needs and that allowed it to take off the way it did
Peter remembers thinking, “ Really? We don’t have five minutes? ” It was shocking
Suddenly there is this medical innovation, which they are told is like a panacea; it can relieve that pain and has virtually no side effects and people can take it forever, and there’s no dosage ceiling
He’s talked to people who’ve said this was a siren song they were all too ready to listen to because it filled a need in their therapeutic arsenal Of course it ended up being more complicated
Of course it ended up being more complicated
Then the patient will be on their way and they never have to see them again
The doctor doesn’t give any thought to how this is working out for them two weeks from now or two months from now or two years from now
It’s that notion that ‘five minutes is money.’
That five minutes is five minutes, they’re not spending with the next patient; it’s a longer line in the waiting room
He thinks those kinds of structural considerations are part of what allowed Purdue and other opioid makers to snow the medical establishment as effectively as they did
He would have thought there would have been more skepticism, that it would have been slower growth
He does think there was a sense in which it sort of filled a number of needs and that allowed it to take off the way it did

Pain, the fifth vital sign

One of the other memories Peter has from the early day of his residence is how all of a sudden a new vital sign emerged Vital signs are, by definition, objective; they are things that can be measured for which there is no ambiguity: temperature, pulse, respiratory rate, blood pressure But then a fifth vital sign was introduced, which was pain Pain is a subjective measurement on a scale of one to 10 There were laminated posters on every corner of the hospital, “ Don’t forget the fifth vital sign. Don’t forget the fifth vital sign. What is the fifth vital sign? What is your patient’s pain? “ And this really came from the medical community; this was a form of self policing
How involved was Purdue in driving this agenda? Patrick says, “‘ very’ would be the short answer ”
Patrick wants to be careful about how he puts this; it’s a tricky thing; it’s a little like when he was talking about Curtis Wright and the FDA There’s a kind of soft corruption that happens, which is not as glaring as the caricature is corruption that one would think of
There is the American Medical Association and all kinds of groups: groups of doctors, groups representing patients, patients’ rights, pain advocacy groups
Then there is the industry underwriting a lot of this stuff There was quite a good piece in Mother Jones just recently about the AMA and Richard Sackler was on one of these boards and there was a lot of money going to sponsor education The Untold Story of Purdue Pharma’s Cozy Relationship With the American Medical Association: The prestigious doctor’s group has made it virtually impossible to discern where public health guidance ends and industry interests begin. Peter just read this article and he couldn’t believe that the AMA, both as an organization and its foundation, separately, are receiving money from the Sacklers
What often happens is that industry groups end up distributing an educational pamphlet or something There’s a kind of institutional laundering that happens, where industry comes up with these educational brochures or they sponsor research etc. The example Patrick loves from the Mother Jones story was that, there was one handy guide to pain and the fifth vital sign, and the idea of how do you talk to a child about the pain they’re feeling; and there was an admonition to the doctors to remember to tell the child that no pain is not an acceptable answer There’s a continuum, but the end of the continuum where there’s no pain, that’s not an option
He thinks it’s more a coincidence of interests, in which there are people who earnestly believe these things and then are underwritten by industry That kind of turbocharges the arguments they’re making, more than it is a situation of docs being paid off to tell what they know to be lies
Back to the idea of the fifth vital sign, even just that phrase, on the one hand, Patrick thinks there was some truth to the critique that there hadn’t been enough education in pain management and enough consideration given to how doctors can relieve patients’ pain On the other hand, when he hears the phrase ‘the fifth vital sign’, that sounds more than anything like a great marketing slogan
Vital signs are, by definition, objective; they are things that can be measured for which there is no ambiguity: temperature, pulse, respiratory rate, blood pressure
But then a fifth vital sign was introduced, which was pain Pain is a subjective measurement on a scale of one to 10 There were laminated posters on every corner of the hospital, “ Don’t forget the fifth vital sign. Don’t forget the fifth vital sign. What is the fifth vital sign? What is your patient’s pain? “ And this really came from the medical community; this was a form of self policing
Pain is a subjective measurement on a scale of one to 10
There were laminated posters on every corner of the hospital, “ Don’t forget the fifth vital sign. Don’t forget the fifth vital sign. What is the fifth vital sign? What is your patient’s pain? “
And this really came from the medical community; this was a form of self policing
Patrick says, “‘ very’ would be the short answer ”
There’s a kind of soft corruption that happens, which is not as glaring as the caricature is corruption that one would think of
There was quite a good piece in Mother Jones just recently about the AMA and Richard Sackler was on one of these boards and there was a lot of money going to sponsor education The Untold Story of Purdue Pharma’s Cozy Relationship With the American Medical Association: The prestigious doctor’s group has made it virtually impossible to discern where public health guidance ends and industry interests begin. Peter just read this article and he couldn’t believe that the AMA, both as an organization and its foundation, separately, are receiving money from the Sacklers
The Untold Story of Purdue Pharma’s Cozy Relationship With the American Medical Association: The prestigious doctor’s group has made it virtually impossible to discern where public health guidance ends and industry interests begin.
Peter just read this article and he couldn’t believe that the AMA, both as an organization and its foundation, separately, are receiving money from the Sacklers
There’s a kind of institutional laundering that happens, where industry comes up with these educational brochures or they sponsor research etc.
The example Patrick loves from the Mother Jones story was that, there was one handy guide to pain and the fifth vital sign, and the idea of how do you talk to a child about the pain they’re feeling; and there was an admonition to the doctors to remember to tell the child that no pain is not an acceptable answer There’s a continuum, but the end of the continuum where there’s no pain, that’s not an option
There’s a continuum, but the end of the continuum where there’s no pain, that’s not an option
That kind of turbocharges the arguments they’re making, more than it is a situation of docs being paid off to tell what they know to be lies
On the other hand, when he hears the phrase ‘the fifth vital sign’, that sounds more than anything like a great marketing slogan

Studies of pain perception

There was a study, Patrick doesn’t recall the citation, but he remembers reading this great study whereon a scale of 1 to 10, what might be a seven for one person could be a nine for another person Rating of pain actually varies regionally They found that people in Northern Europe, when exposed to some sort of standard amount of pain, they would say, “ Oh, that’s a four ” And then people in Southern Europe, exposed to the same amount of pain, they would say, “ It’s a 10, it’s a 10 ” They reported these cultural, regional differences in terms of people’s pain thresholds
It’s hard, because he does think it’s a legitimate thing that people should be looking at and inquiring about, but at the same time, it’s totally subjective
And he thinks that again and again, “ you see just the money pollute everything ”
Rating of pain actually varies regionally They found that people in Northern Europe, when exposed to some sort of standard amount of pain, they would say, “ Oh, that’s a four ” And then people in Southern Europe, exposed to the same amount of pain, they would say, “ It’s a 10, it’s a 10 ” They reported these cultural, regional differences in terms of people’s pain thresholds
They found that people in Northern Europe, when exposed to some sort of standard amount of pain, they would say, “ Oh, that’s a four ”
And then people in Southern Europe, exposed to the same amount of pain, they would say, “ It’s a 10, it’s a 10 ”
They reported these cultural, regional differences in terms of people’s pain thresholds

Other players that helped facilitate the eventual opioid crisis [1:16:15]

Soft corruption in many levels of government

Peter notes that Patrick mentioned earlier that Curtis Wright, effectively (whether in a direct quid pro quo or more of just a confluence of interests) approves this drug single handedly for the FDA, and then ultimately, winds up working for this entity
The other story in this one that really blew his mind was that of Linden Barber, at the DEA On the one hand, he seems by all accounts to be one of the most credible voices within the DEA standing up to the unmanaged distribution of these drugs Then he does an about-face and becomes one of the most powerful lobbying entities for these very companies Peter believes Cardinal was one of his largest clients, McKesson being another; these were 2 of the largest distributors. It’s kind of hard to believe I guess it’s like Patrick said earlier, “ Look, how long can you work for nothing as a government employee? ” And at some point, he has a choice, which is he’s going to go make a living, harnessing his existing skills But it just doesn’t feel right
Patrick notes that he has written a fair amount about crime where it’s just kind of baked-in, that he’s writing about a bad person doing a bad thing, but this has been one of the more dispiriting things, working on this project Usually there’s a sort of moral clarity there, they kind of know they’re bad What was so fascinating to him about this story is, he thinks the Sacklers are bad actors He thinks they did really bad things and they’re the focus of the story But then around them are all of these facilitators Former prosecutors who go and work as private defense attorneys for the family or for the company Former DEA officials who go and work as lobbyists for the industry Former FDA officials who go and work at the company Folks at McKinsey It’s this whole kind of amazing, entrenched machine of people who, in many instances, don’t think of themselves as the bad guys And in some cases, society doesn’t think of them as the bad guys One of the characters in his book is Mary Jo White , former US attorney for the Southern district of New York She was Obama’s head of the SEC; a woman who broke the glass ceiling She has represented Purdue and the Sacklers for years, and is totally a handmaiden to them
This is a thing that he’s wrestled with personally, he’s a lawyer by training, and he knows that it’s fundamental to the ethos of the profession that one shouldn’t necessarily transpose the moral stink of the client onto the lawyer But it’s hard for him when he hears the Linden Barber story There’s a hundred people like that in the book, who play that kind of role again and again, and again Further, there are these people who were supposed to be the cops, they’re supposed to be law and order and they get co-opted by the money and it’s really discouraging
Peter notes that sometimes it isn’t even that much money involved Look at Chris Dodd and Marsha Blackburn and Tom Marino and Orrin Hatch ; it’s just hard to look at these people and think of them as reasonable or respectable, truthfully, when he knows their involvement in this, and the bills that they sponsored, and the positions that they took in all of this; and to know they were bought so cheaply
On the one hand, he seems by all accounts to be one of the most credible voices within the DEA standing up to the unmanaged distribution of these drugs
Then he does an about-face and becomes one of the most powerful lobbying entities for these very companies Peter believes Cardinal was one of his largest clients, McKesson being another; these were 2 of the largest distributors. It’s kind of hard to believe I guess it’s like Patrick said earlier, “ Look, how long can you work for nothing as a government employee? ” And at some point, he has a choice, which is he’s going to go make a living, harnessing his existing skills But it just doesn’t feel right
Peter believes Cardinal was one of his largest clients, McKesson being another; these were 2 of the largest distributors.
It’s kind of hard to believe
I guess it’s like Patrick said earlier, “ Look, how long can you work for nothing as a government employee? ” And at some point, he has a choice, which is he’s going to go make a living, harnessing his existing skills But it just doesn’t feel right
But it just doesn’t feel right
Usually there’s a sort of moral clarity there, they kind of know they’re bad
What was so fascinating to him about this story is, he thinks the Sacklers are bad actors
He thinks they did really bad things and they’re the focus of the story
But then around them are all of these facilitators Former prosecutors who go and work as private defense attorneys for the family or for the company Former DEA officials who go and work as lobbyists for the industry Former FDA officials who go and work at the company Folks at McKinsey It’s this whole kind of amazing, entrenched machine of people who, in many instances, don’t think of themselves as the bad guys And in some cases, society doesn’t think of them as the bad guys
One of the characters in his book is Mary Jo White , former US attorney for the Southern district of New York She was Obama’s head of the SEC; a woman who broke the glass ceiling She has represented Purdue and the Sacklers for years, and is totally a handmaiden to them
Former prosecutors who go and work as private defense attorneys for the family or for the company
Former DEA officials who go and work as lobbyists for the industry
Former FDA officials who go and work at the company
Folks at McKinsey
It’s this whole kind of amazing, entrenched machine of people who, in many instances, don’t think of themselves as the bad guys
And in some cases, society doesn’t think of them as the bad guys
She was Obama’s head of the SEC; a woman who broke the glass ceiling
She has represented Purdue and the Sacklers for years, and is totally a handmaiden to them
But it’s hard for him when he hears the Linden Barber story
There’s a hundred people like that in the book, who play that kind of role again and again, and again
Further, there are these people who were supposed to be the cops, they’re supposed to be law and order and they get co-opted by the money and it’s really discouraging
Look at Chris Dodd and Marsha Blackburn and Tom Marino and Orrin Hatch ; it’s just hard to look at these people and think of them as reasonable or respectable, truthfully, when he knows their involvement in this, and the bills that they sponsored, and the positions that they took in all of this; and to know they were bought so cheaply

“US senators for sale for hundreds of thousands of dollars? I don’t understand it.” – Peter Attia

Patrick thinks money donations are part of it; but it is more about the revolving door Lobbyist are often people they know An example is the way in which Purdue and the Salkers would use lawyers like Mary Jo White Similarly, they hired Rudy Giuliani for years; he was kind of their hatchet man Think of it as if “ you were a federal prosecutor and you’re investigating me, the real move is not to sort of fight it out with you on the merits in court, the way most people would, it’s for me to go to your boss, but not for me personally to go to your boss, for me to find somebody who your boss knows and respects, and that’s the person I buy off and I send them to go and kind of make the overture ”
When one looks at these people, it’s the sort of soft corruption It’s not campaign contributions It’s that scene in The Godfather where the guy’s supposed to testify in court, and they get the old guy from Sicily to come and just sit in the courtroom and it happens to be his uncle or whatever, and he sees the guy in the courtroom and he suddenly sort of loses all his moral conviction and decides he’s not going to testify It’s being really smart and strategic about who’s the right messenger Who would be sent to make the case to Chris Dodd, about why he shouldn’t come after Purdue, or why he should help them in this or that And Purdue and the Sacklers are really, really good at that
Peter wonders how bipartisan this ‘corruption’ was Was it the bill H.R.4709? This was a sleeper bill, right? It was maybe three pages, a “nothing burger” that basically opened the pipelines to move these drugs and put the DA’s hands behind its back It’s amazing how unopposed that bill went Patrick thinks the fact is that nobody’s really reading the bill The bill was carefully designed to look like it was doing the opposite of what it was doing It has the appearance of fighting the opioid crisis Obama signed it and who knows how closely he looked at it There’s enough business that goes on in Washington, particularly when it comes to lawmaking, there are these members of the house and senators who spend all their time raising money and if they can make what they’re doing,look like business as usual, they can pull it off It’s super dispiriting
The opioid painkiller industry spends something like seven or eight times what the gun lobby spends on lobbying in Washington Just imagine the kind of impact they can have on the legislative picture
An example involving Purdue involves a long period of time where all these states were trying to respond at a state level to the opioid crisis States were trying to introduce new legislation to shut down pill mills or go after bad docs and what have you There were these legislative initiatives at a state level that got set up and Purdue found the right state lobbyists to go to the state Capitol and help neuter those bills as best they can And they were very successful at doing that
Lobbyist are often people they know
An example is the way in which Purdue and the Salkers would use lawyers like Mary Jo White
Similarly, they hired Rudy Giuliani for years; he was kind of their hatchet man
Think of it as if “ you were a federal prosecutor and you’re investigating me, the real move is not to sort of fight it out with you on the merits in court, the way most people would, it’s for me to go to your boss, but not for me personally to go to your boss, for me to find somebody who your boss knows and respects, and that’s the person I buy off and I send them to go and kind of make the overture ”
It’s not campaign contributions
It’s that scene in The Godfather where the guy’s supposed to testify in court, and they get the old guy from Sicily to come and just sit in the courtroom and it happens to be his uncle or whatever, and he sees the guy in the courtroom and he suddenly sort of loses all his moral conviction and decides he’s not going to testify
It’s being really smart and strategic about who’s the right messenger
Who would be sent to make the case to Chris Dodd, about why he shouldn’t come after Purdue, or why he should help them in this or that And Purdue and the Sacklers are really, really good at that
And Purdue and the Sacklers are really, really good at that
Was it the bill H.R.4709?
This was a sleeper bill, right?
It was maybe three pages, a “nothing burger” that basically opened the pipelines to move these drugs and put the DA’s hands behind its back It’s amazing how unopposed that bill went
Patrick thinks the fact is that nobody’s really reading the bill The bill was carefully designed to look like it was doing the opposite of what it was doing It has the appearance of fighting the opioid crisis Obama signed it and who knows how closely he looked at it There’s enough business that goes on in Washington, particularly when it comes to lawmaking, there are these members of the house and senators who spend all their time raising money and if they can make what they’re doing,look like business as usual, they can pull it off It’s super dispiriting
It’s amazing how unopposed that bill went
The bill was carefully designed to look like it was doing the opposite of what it was doing
It has the appearance of fighting the opioid crisis
Obama signed it and who knows how closely he looked at it
There’s enough business that goes on in Washington, particularly when it comes to lawmaking, there are these members of the house and senators who spend all their time raising money and if they can make what they’re doing,look like business as usual, they can pull it off
It’s super dispiriting
Just imagine the kind of impact they can have on the legislative picture
States were trying to introduce new legislation to shut down pill mills or go after bad docs and what have you
There were these legislative initiatives at a state level that got set up and Purdue found the right state lobbyists to go to the state Capitol and help neuter those bills as best they can And they were very successful at doing that
And they were very successful at doing that

“When you have a drug that’s generated $35 billion in revenue, the amount of influence you can buy is just awesome” – Patrick Radden Keefe

Lack of accountability following the investigation and prosecution of Purdue and the Sackler family [1:23:30]

Initial attempt to prosecute were foiled by company influence

There were a couple of investigators, at a small federal prosecutor’s office in the Western district of Virginia Their community had been appended by OxyContin, specifically They started realizing, “ all this pharmacy theft and crime is going up and you get people out DIYing when they started investigating ” and to them, it was this kind of weird thing where they felt a hurricane had just hit their town They wondered where it came from it came from Connecticut They did this really amazing investigation They spent 5 years investigating Purdue They subpoenaed millions of documents They did huge amounts of grand jury testimony and wanted to charge three senior executives at the company with felonies The idea was that faced with jail time, these executives would flip on the Sacklers One of those federal prosecutors has said this on the record that the plan was actually to target the Sacklers, if they could flip these guys; and this was confirmed by another What ended up happening was that the company sent Rudy Giuliani and Mary Jo White to go over the heads of those federal prosecutors, to go to the George W. Bush justice department in Washington and say, “ You can’t go after these guys for felonies. We need to take felonies off the table, take jail time off the table. ” The prosecutors got overruled by their own bosses This was Alice Fisher and Paul McNulty Patrick talked to them and asked, “Who made that decision to tell these prosecutors in the Western district of Virginia? “ They just pointed at each other; nobody would own it
Their community had been appended by OxyContin, specifically
They started realizing, “ all this pharmacy theft and crime is going up and you get people out DIYing when they started investigating ” and to them, it was this kind of weird thing where they felt a hurricane had just hit their town
They wondered where it came from it came from Connecticut
They did this really amazing investigation They spent 5 years investigating Purdue They subpoenaed millions of documents They did huge amounts of grand jury testimony and wanted to charge three senior executives at the company with felonies The idea was that faced with jail time, these executives would flip on the Sacklers
One of those federal prosecutors has said this on the record that the plan was actually to target the Sacklers, if they could flip these guys; and this was confirmed by another
What ended up happening was that the company sent Rudy Giuliani and Mary Jo White to go over the heads of those federal prosecutors, to go to the George W. Bush justice department in Washington and say, “ You can’t go after these guys for felonies. We need to take felonies off the table, take jail time off the table. ”
The prosecutors got overruled by their own bosses This was Alice Fisher and Paul McNulty Patrick talked to them and asked, “Who made that decision to tell these prosecutors in the Western district of Virginia? “ They just pointed at each other; nobody would own it
They spent 5 years investigating Purdue
They subpoenaed millions of documents
They did huge amounts of grand jury testimony and wanted to charge three senior executives at the company with felonies
The idea was that faced with jail time, these executives would flip on the Sacklers
This was Alice Fisher and Paul McNulty
Patrick talked to them and asked, “Who made that decision to tell these prosecutors in the Western district of Virginia? “
They just pointed at each other; nobody would own it

“You would think, all these years on a pretty consequential decision, you would think that somebody might take responsibility for it.” – Patrick Radden Keefe

What that meant was that, because they couldn’t charge Purdue executives with felonies, these guys weren’t going to flip They pled to misdemeanors Prosecutors couldn’t go after the Sacklers The company paid a $600 million fine and pled guilty to felony charges of misbranding Then it was pretty much business as usual; they didn’t even slow down their marketing a job
They pled to misdemeanors
Prosecutors couldn’t go after the Sacklers
The company paid a $600 million fine and pled guilty to felony charges of misbranding
Then it was pretty much business as usual; they didn’t even slow down their marketing a job

Guilty pleas and bankruptcy

But in the last couple years, Purdue went into bankruptcy and more importantly this third party release This seems to be a very important granting on the part of a one White Plains bankruptcy judge
In 2007, the company pleaded guilty
The official line after that was, “ Oh, we cleaned up our act. We had a few bad apples, but everything’s okay now. ” But they didn’t really change a whole lot Really all the senior folks, the three guys who pled guilty to misdemeanors had to leave; they couldn’t keep working at the company But other than that, all the senior folks who were involved in this stuff stayed on; heads did not roll
Purdue kind of kept doing what it was doing
In 2020, the company pled guilty to a new set of federal criminal charges and the conduct that it pled to, dated back 10 years They pleaded guilty in 2007, and then in theory, there was a couple of years of good behavior, but then starting in about 2010, they were back to committing crimes and kept at it through 2020, when they pled guilty again
In between those two guilty pleas there are lots of lawsuits Some of these are private, class action lawsuits, lawsuits brought by: hospitals, school districts, cities, states Eventually every state in the union pretty much, is suing Purdue over its role in the opioid crisis
What’s happening in parallel to that, which we didn’t know about until fairly recently, is that starting in 2007 after that guilty plea, the Sacklers start quietly taking money out of the company They’re just sort of siphoning money out a hundred million here, a hundred million there; over the course of about a decade, they take more than $10 billion out of the company
In 2018-2019, there are thousands of lawsuits against the company
The companies is on the ropes, and the family kicks the company into bankruptcy
This seems to be a very important granting on the part of a one White Plains bankruptcy judge
But they didn’t really change a whole lot
Really all the senior folks, the three guys who pled guilty to misdemeanors had to leave; they couldn’t keep working at the company
But other than that, all the senior folks who were involved in this stuff stayed on; heads did not roll
They pleaded guilty in 2007, and then in theory, there was a couple of years of good behavior, but then starting in about 2010, they were back to committing crimes and kept at it through 2020, when they pled guilty again
Some of these are private, class action lawsuits, lawsuits brought by: hospitals, school districts, cities, states
Eventually every state in the union pretty much, is suing Purdue over its role in the opioid crisis
They’re just sort of siphoning money out a hundred million here, a hundred million there; over the course of about a decade, they take more than $10 billion out of the company

“They say the company doesn’t have any money anymore, which is only the case because they took $10 billion out of it” – Patrick Radden Keefe

The Sacklers seek immunity

Since the company is bankrupt now, all these lawsuits against them are suspended
They ended up in this bankruptcy court in White Plains, New York , because this is the way bankruptcy law works They got to pick their judge One can decide where to declare bankruptcy, corporate bankruptcy They picked this judge who they thought would be sympathetic
This is where it gets really interesting, by this point, roughly half of the states were not just suing the company, they were suing individual members of the family, who had sat on the company’s board
There’s a move by the company and the family to say, “ Okay, so you’ve suspended all these lawsuits against the company, because it’s in bankruptcy, but we want you to suspend the lawsuits against the family too, even though they haven’t declared bankruptcy. ”
And the judge did that temporarily, which is pretty controversial There are states in which one is able to do that They are not able to say to the attorney general of half of the states, “ No, you cannot bring your lawsuit “; but a federal bankruptcy judge in New York says to the state attorney general of Idaho, “ No, you cannot bring your state based claim .” It’s pretty exotic, but he did.
Now it’s in sort of an end game, where the Sacklers have made this bid to permanently immunize them from any litigation (and they want the judge to make this permanent) The phrase for this,is nonconsensual third-party releases This is happening in real time, now; there’s a bankruptcy trial going on with testimony, but I think everybody knows how it’s going to end The judge has kind of telegraphed where he’s going with this
They got to pick their judge
One can decide where to declare bankruptcy, corporate bankruptcy
They picked this judge who they thought would be sympathetic
There are states in which one is able to do that
They are not able to say to the attorney general of half of the states, “ No, you cannot bring your lawsuit “; but a federal bankruptcy judge in New York says to the state attorney general of Idaho, “ No, you cannot bring your state based claim .” It’s pretty exotic, but he did.
It’s pretty exotic, but he did.
The phrase for this,is nonconsensual third-party releases
This is happening in real time, now; there’s a bankruptcy trial going on with testimony, but I think everybody knows how it’s going to end
The judge has kind of telegraphed where he’s going with this

Proposed settlement

There are some states that continue to fight effectively
Basically, this is a situation in which the Sacklers have made a proposal to, in one fell swoop, deal with all this litigation once and for all And they’re doing it in the context of this bankruptcy proceeding, where they say, “ We will pay $4.5 billion of our money to remediate the opioid crisis. We’ll pay it out over nine years and we’ll make no admission of wrongdoing, we’ll give up our interest in Purdue, we’ll be granted one of these nonconsensual third-party releases, ” where basically, this judge gets to waive his wand and say, “ Nobody can ever sue you again. No state prosecutor, no private plaintiff, nobody can sue you ever again over anything having to do with OxyContin or the opioid crisis. ”
Patrick thinks there are a lot of states that are desperate and fighting, dealing with the trillions of dollars in public costs that this crisis has generated They’re reeling; they see $4.5 billion, and they think, “ I could use one 50th of that. ” So they’re inclined to take the deal, even if they don’t like it
And they’re doing it in the context of this bankruptcy proceeding, where they say, “ We will pay $4.5 billion of our money to remediate the opioid crisis. We’ll pay it out over nine years and we’ll make no admission of wrongdoing, we’ll give up our interest in Purdue, we’ll be granted one of these nonconsensual third-party releases, ” where basically, this judge gets to waive his wand and say, “ Nobody can ever sue you again. No state prosecutor, no private plaintiff, nobody can sue you ever again over anything having to do with OxyContin or the opioid crisis. ”
They’re reeling; they see $4.5 billion, and they think, “ I could use one 50th of that. ”
So they’re inclined to take the deal, even if they don’t like it

“To put that $4.5 billion number in perspective, the Sacklers still having an $11 billion fortune, and they’re going to pay out the $4.5 over nine years.” – Patrick Radden Keefe

A lot of people look at this and feel this isn’t justice The payment is actually not linearly weighted; the majority of it comes at the end of the 9 years, so in theory, they could come out ahead if they invest reasonably well Patrick had some conversations with people who advise high-net-worth families and invest their fortunes, and conservatively, between interests and a very conservative portfolio, they can probably expect a 5% return on that $11 billion fortune If that’s the case, they would never have to touch their principal In absolute terms, it’s a lot of money, but it doesn’t commensurate to the damage Ultimately, it’ll be a pretty good deal for the Sacklers And this is how he thinks it’s going to shake out
What else will this accomplish?
No amount of money is going to bring back a loved one
Peter has several patients whose lives have been directly impacted by this, whose children have overdosed, kids that became addicted to prescription pain pills. In one situation, one of the kids was clean for a number of months, then was at a party where someone suggested he try a pill It turned out to be laced with fentanyl; this story ends tragically No amount of money is going to fix that
So whether the Sacklers have to give $4.5 billion or forfeit every dollar they’ve ever made and will make in perpetuity, that never brings back a life
The payment is actually not linearly weighted; the majority of it comes at the end of the 9 years, so in theory, they could come out ahead if they invest reasonably well
Patrick had some conversations with people who advise high-net-worth families and invest their fortunes, and conservatively, between interests and a very conservative portfolio, they can probably expect a 5% return on that $11 billion fortune If that’s the case, they would never have to touch their principal In absolute terms, it’s a lot of money, but it doesn’t commensurate to the damage Ultimately, it’ll be a pretty good deal for the Sacklers And this is how he thinks it’s going to shake out
If that’s the case, they would never have to touch their principal
In absolute terms, it’s a lot of money, but it doesn’t commensurate to the damage
Ultimately, it’ll be a pretty good deal for the Sacklers
And this is how he thinks it’s going to shake out
In one situation, one of the kids was clean for a number of months, then was at a party where someone suggested he try a pill
It turned out to be laced with fentanyl; this story ends tragically
No amount of money is going to fix that

Justice and trends in corporate accountability

Justice is about 3 things 1) It’s about how much can be fixed today with money because maybe some things can be fixed with money, some things can’t 2) Is justice being served? 3) Is this creating a deterrent for another entity in the future to be a little more careful with what they do? Is this a sufficient deterrent for the foreseeable future, to put the legal/illicit drug market on notice? Insys Therapeutics was different because their people went to jail
Patrick sees this as part of a larger trend that’s been happening over the last 10 or 15 years, since the days of Enron and WorldCom , which is that there’s a pronounced disinclination – this is across political parties – to bring criminal charges and jail time into the equation when it comes to corporate executives acting within their role, even if the conduct is criminal
It is bizarre that Purdue Pharma pled guilty for a second time in 2020, and there were no individual executives, even names.; it’s like it’s a driverless car
1) It’s about how much can be fixed today with money because maybe some things can be fixed with money, some things can’t
2) Is justice being served?
3) Is this creating a deterrent for another entity in the future to be a little more careful with what they do? Is this a sufficient deterrent for the foreseeable future, to put the legal/illicit drug market on notice? Insys Therapeutics was different because their people went to jail
Is this a sufficient deterrent for the foreseeable future, to put the legal/illicit drug market on notice?
Insys Therapeutics was different because their people went to jail

“How is it that the company could commit federal crimes if there’s no individuals who can be identified as having committed crimes? It doesn’t make any sense.” – Patrick Radden Keefe

It’s reflective of the general posture of the Justice Department and our whole system of justice, broadly speaking, which is, it’s really the exception when a corporate executive ends up doing jail time, as happened with Insys The Insys case is particularly extreme Insys is everything seen in the Purdue story, but dialed up to 11 There were a bunch of reasons why jail time was handed out in the Insys case and not in the context of Purdue or J&J
John Kapoor was the CEO of Insys Therapeutics who was convicted and sentenced to 5.5 years of prison Patrick comments that Insys was such a scam; they had strippers working as sales reps and fairly bald bribery schemes, not the soft corruption he’s been talking about, but the hardest of hard corruption This is why there was jail time
In Patrick’s view, jail time is the only thing that really is a deterrent
Otherwise, when it comes to money, people think about risk; they evaluate risk
The Insys case is particularly extreme
Insys is everything seen in the Purdue story, but dialed up to 11
There were a bunch of reasons why jail time was handed out in the Insys case and not in the context of Purdue or J&J
Patrick comments that Insys was such a scam; they had strippers working as sales reps and fairly bald bribery schemes, not the soft corruption he’s been talking about, but the hardest of hard corruption This is why there was jail time
This is why there was jail time

Legacy of the Sackler family and their disconnect from reality [1:34:45]

Costs to the Sacklers

Look at the Sacklers; they take $10 billion out of a company during a period of time when it’s committing crimes To have to give back $4.5 billion… should they do it? Look at that fact pattern; the company commits crimes, and the owners and board of the company are never going to go to jail; they’ll never get charged with any crimes To give back 4.5 billion over nine years; this is their risk
For the Sacklers,the real costs are going to be reputational, and it’s hard to measure that
Peter asks if they are any different from OJ Simpson It’s hard to say
If one considers just those who have OD’ed on OxyContin, they would say, “ Ah, yes, but there were other drugs in their systems. ”
But, of the half a million people who have died in the last two decades, probably some subset, maybe a small subset, of those people, the blood is on the hands of this family
Peter notes that work like Patrick’s has really brought that to light He wonders what the rest of their lives will look like Will this be basically forgotten about? Will the next generation of Sacklers carry no shame for this? Or will this be something that forever makes people in polite company a bit embarrassed to be around them?
Patrick thinks these last 2 things are going to be the case; people will forever be embarrassed to be around them He thinks the name is toxic; it’s coming down off of institutions, and he thinks it’ll come down off of more institutions He thinks that the family isn’t happy about that But he also doesn’t know that any of them feel any shame
To have to give back $4.5 billion… should they do it?
Look at that fact pattern; the company commits crimes, and the owners and board of the company are never going to go to jail; they’ll never get charged with any crimes
To give back 4.5 billion over nine years; this is their risk
It’s hard to say
He wonders what the rest of their lives will look like
Will this be basically forgotten about?
Will the next generation of Sacklers carry no shame for this?
Or will this be something that forever makes people in polite company a bit embarrassed to be around them?
He thinks the name is toxic; it’s coming down off of institutions, and he thinks it’ll come down off of more institutions
He thinks that the family isn’t happy about that
But he also doesn’t know that any of them feel any shame

The family’s disconnect from reality

Patrick thought one analogy a lot while writing this book in the last years of the Trump presidency The Sackler situation is a little similar to Trump’s In both cases there is a billionaire surrounded by advisors, lawyers, and PR people; all these people whose livelihood depends on keeping them happy Patric thinks for both there is a heightened danger of delusion, of them getting out of touch with reality And it probably starts in small ways; they tell a joke, and everybody in the room laughs So initially, they’re just a millimeter or two off track, in terms of the fidelity of their perceptions of the world The longer they go, the further off course they get, and what everyone saw with Trump, it’s also seen with the Sacklers
Patrick talked to people who, a decade ago, said to the family, “ What if you took some of this philanthropic money that you give to art museums and started a foundation, dedicated to the study of addiction, redressing the opioid crisis? ” These people were making a cynical argument, but saying, “ Just purely in terms of the optics here, you should make some gesture recognizing that there’s a problem and that people think that you’re responsible for it. ” And those people were always sidelined and fired The people who end up in the inner circle are the ones who say, “ You are just terribly misunderstood. All these people don’t understand you, the press, the public, the people making jokes on the late show, the Attorneys General of every single state, all these members of Congress who keep condemning you, all these studies that are done about OxyContin and its legacy. It’s all just a big misunderstanding. You never did anything wrong .”
It’s astonishing to Patrick, but the family members tend to pretty uniformly feel that way, that they did nothing wrong
Peter is amazed that with the size of the Sackler family, when he thinks about how many children the three Sackler brothers had, and how many children they had, and how many spouses they have, that’s a pretty good list of people who could have come forth and said something to you, even off the record or on background; and yet this didn’t happen
Patrick’s assumption from the beginning had been that there must be some apostate, third-generation Sackler who looks around, and never mind his writing, they read the New York Times , they read the LA Times , they read Sam Quinones ‘ book Dreamland , and they say, “ My trust fund is blood money; I don’t need this; I’m going to turn my back on it ” But he couldn’t find one
One of the more revealing documents is a WhatsApp log It’s a chat log from the heirs of Mortimer Sackler This came out in the context of the bankruptcy proceeding, where they all talk over the course of a couple of years, all these different family members, siblings, cousins They’re talking about their problems, and how to deal with it, and the litigation and the bad PR, and what’s the right strategy? It’s this private channel, and there’s nobody, nobody, who at any point says, “ Geez, maybe our critics have a point ” Or “ Maybe we should ask some tough questions ” Instead, it’s this pretty lockstep feeling among family members of persecution Even more, the way they talk amongst themselves, at times, it feels as though, in their minds, the real victims of the opioid crisis are the Sackler family
For the Sackler family, there’s no awareness, not a shred of introspection
Instead they have a profound sense of grievance, a sense that they’ve been persecuted
There’s this amazing email that Patrick quotes in the book, where Jacqueline Sackler (married to Mortimer Jr., a second-generation member who was on the board of the company) is talking about how all this press coverage and this stigma for the family She’s worried about her children applying to elite private schools in Manhattan in the fall and their chances; and in the context of griping about this, she says, “C hildren’s lives are being destroyed “ Not to pivot from the comic to the tragic, but he gets emails every week from people who lost children When one hears from as many bereaved parents as he does, it’s just amazing to read an email like that and consider the level of disconnection that it betrays
The Sackler situation is a little similar to Trump’s
In both cases there is a billionaire surrounded by advisors, lawyers, and PR people; all these people whose livelihood depends on keeping them happy
Patric thinks for both there is a heightened danger of delusion, of them getting out of touch with reality And it probably starts in small ways; they tell a joke, and everybody in the room laughs So initially, they’re just a millimeter or two off track, in terms of the fidelity of their perceptions of the world The longer they go, the further off course they get, and what everyone saw with Trump, it’s also seen with the Sacklers
And it probably starts in small ways; they tell a joke, and everybody in the room laughs
So initially, they’re just a millimeter or two off track, in terms of the fidelity of their perceptions of the world
The longer they go, the further off course they get, and what everyone saw with Trump, it’s also seen with the Sacklers
These people were making a cynical argument, but saying, “ Just purely in terms of the optics here, you should make some gesture recognizing that there’s a problem and that people think that you’re responsible for it. ”
And those people were always sidelined and fired
The people who end up in the inner circle are the ones who say, “ You are just terribly misunderstood. All these people don’t understand you, the press, the public, the people making jokes on the late show, the Attorneys General of every single state, all these members of Congress who keep condemning you, all these studies that are done about OxyContin and its legacy. It’s all just a big misunderstanding. You never did anything wrong .”
But he couldn’t find one
It’s a chat log from the heirs of Mortimer Sackler
This came out in the context of the bankruptcy proceeding, where they all talk over the course of a couple of years, all these different family members, siblings, cousins
They’re talking about their problems, and how to deal with it, and the litigation and the bad PR, and what’s the right strategy?
It’s this private channel, and there’s nobody, nobody, who at any point says, “ Geez, maybe our critics have a point ” Or “ Maybe we should ask some tough questions ”
Instead, it’s this pretty lockstep feeling among family members of persecution
Even more, the way they talk amongst themselves, at times, it feels as though, in their minds, the real victims of the opioid crisis are the Sackler family
She’s worried about her children applying to elite private schools in Manhattan in the fall and their chances; and in the context of griping about this, she says, “C hildren’s lives are being destroyed “
Not to pivot from the comic to the tragic, but he gets emails every week from people who lost children
When one hears from as many bereaved parents as he does, it’s just amazing to read an email like that and consider the level of disconnection that it betrays

Patrick’s views on the regulation and use of pain management drugs [1:42:15]

The legacy of Patrick’s book Empire of Pain

Patrick hears from basically 2 groups of people: 1) People who have become addicted or family members and friends of people who have become addicted or tragically died 2) People using these pain medications who say, “Y our work is potentially threatening to the supply of pain medication to people like me, who genuinely and legitimately need it ”
There’s a fine line here, an overreaction or an overcorrection would limit the supply of or access to for patients who do need pain medication There is a definite sense in which the pendulum has swung back and many doctors are less likely to prescribe these drugs in the first place; they’re more likely to prescribe shorter courses at lower doses He thinks a lot of that is a good thing, ultimately
He gets emails from many chronic pain patients who are fearful that ther supply of prescription opioid painkillers, that they probably count on in order to function in life, is really jeopardized by these changing currents in terms of the way in which people perceive these drugs This is an incredibly difficult thing He is very sympathetic to this; he certainly doesn’t want to see people who use these drugs stigmatized, whether they use them legally or illegally
He’s also not a prohibitionist Given all his work on illegal drugs, he tends to think that drug prohibition is not the way to go People make argument that if policies cut off pain patients, forcing them to do a rapid taper, that this might actually drive people onto the black market and become more unsafe; that this might be part of what’s driving the opioid crisis
He balks at the suggestion that he shouldn’t write about the Sacklers and their culpability, because there might be some second- or third-order consequences of that, or that his focus is in the wrong place He’s going to write the books (and articles) that he wants to write a It’s very often the case that people who are telling him that he shouldn’t be doing these things, generally speaking, haven’t read the book, haven’t really engaged with the particulars all that much
1) People who have become addicted or family members and friends of people who have become addicted or tragically died
2) People using these pain medications who say, “Y our work is potentially threatening to the supply of pain medication to people like me, who genuinely and legitimately need it ”
There is a definite sense in which the pendulum has swung back and many doctors are less likely to prescribe these drugs in the first place; they’re more likely to prescribe shorter courses at lower doses He thinks a lot of that is a good thing, ultimately
He thinks a lot of that is a good thing, ultimately
This is an incredibly difficult thing
He is very sympathetic to this; he certainly doesn’t want to see people who use these drugs stigmatized, whether they use them legally or illegally
Given all his work on illegal drugs, he tends to think that drug prohibition is not the way to go
People make argument that if policies cut off pain patients, forcing them to do a rapid taper, that this might actually drive people onto the black market and become more unsafe; that this might be part of what’s driving the opioid crisis
He’s going to write the books (and articles) that he wants to write a
It’s very often the case that people who are telling him that he shouldn’t be doing these things, generally speaking, haven’t read the book, haven’t really engaged with the particulars all that much

The difficult path forward [1:44:45]

Patrick thinks this has been an agonizing period for pain patients because the problem was not that a drug like OxyContin shouldn’t have been produced or made available to them; the problem was the decision in the medical community to do 2 things: 1) Dramatically expand the universe of people who should be taking these drugs 2) Play down the risks, pretty systematically, so that there’s a dishonesty with the consumer and with physicians about what the dangers are
He doesn’t think that these drugs should not be available at all There are some who do, some doctors do He is pretty squarely focused on the origins of the crisis and some pretty unambiguous wrongs perpetrated by Purdue and the Sacklers
If the Sacklers represent a cancer, that cancer has largely been excised The Sacklers themselves are no longer going to be a part of this dilemma But unfortunately, the cancer metastasized before it was excised; there is still an opioid crisis
1) Dramatically expand the universe of people who should be taking these drugs
2) Play down the risks, pretty systematically, so that there’s a dishonesty with the consumer and with physicians about what the dangers are
There are some who do, some doctors do
He is pretty squarely focused on the origins of the crisis and some pretty unambiguous wrongs perpetrated by Purdue and the Sacklers
The Sacklers themselves are no longer going to be a part of this dilemma
But unfortunately, the cancer metastasized before it was excised; there is still an opioid crisis

Scale of the current opioid crisis

The opioid crisis doesn’t show any signs of abatement; in fact, last year more people died of opioid overdose than any other cause of accidental death This is a staggering statistic when one considers how many people die in car accidents or how many people die of gunshot wounds
The question of what is the path forward, what is the path to address this crisis is one that overwhelms Patrick He has simply taken a small piece of the opioid crisis to focus on it and understand it For him, it was looking at the origin story of the crisis more than where the crisis is now
The numbers are staggering and getting worse
Patrick feels that the Sacklers are not absolved by the fact that the crisis today is a heroin and fentanyl crisis He has the sense in which there are many, many people who would never have taken heroin or fentanyl in the first instance, that started on prescription opioids like OxyContin But, from the vantage point of today, he’d rather people be abusing OxyContin than abusing fentanyl or heroin that’s laced with who knows what It is a very, very scary situation
This is a staggering statistic when one considers how many people die in car accidents or how many people die of gunshot wounds
He has simply taken a small piece of the opioid crisis to focus on it and understand it
For him, it was looking at the origin story of the crisis more than where the crisis is now
He has the sense in which there are many, many people who would never have taken heroin or fentanyl in the first instance, that started on prescription opioids like OxyContin
But, from the vantage point of today, he’d rather people be abusing OxyContin than abusing fentanyl or heroin that’s laced with who knows what
It is a very, very scary situation

Resources to address this crisis

He feels that more resources are needed than are currently available This is a problem that needs to be resources Treatment is often not available to people There is still a huge amount of stigma associated with the abuse of and addiction, when it comes to these types of drugs Anything that can be done to diminish that stigma would help Medically assisted treatment would help, which, he thinks there are still some for whom that’s a scary concept This should be adopted and embraced and not cause the consternation that it does for some
This is a huge national crisis
Prior to COVID there was a recognition that a major national strategy was needed to deal with this That it’s out of control and killing people in vast numbers That the country needs to have all ideas on the table and be strategic and resource the solution
Then COVID came along, and there just wasn’t really the bandwidth or the oxygen in the room to have this conversation
This is a problem that needs to be resources
Treatment is often not available to people
There is still a huge amount of stigma associated with the abuse of and addiction, when it comes to these types of drugs Anything that can be done to diminish that stigma would help Medically assisted treatment would help, which, he thinks there are still some for whom that’s a scary concept This should be adopted and embraced and not cause the consternation that it does for some
Anything that can be done to diminish that stigma would help
Medically assisted treatment would help, which, he thinks there are still some for whom that’s a scary concept This should be adopted and embraced and not cause the consternation that it does for some
This should be adopted and embraced and not cause the consternation that it does for some
That it’s out of control and killing people in vast numbers
That the country needs to have all ideas on the table and be strategic and resource the solution

“But when we neglect the problem, as we have during COVID, purely in terms of the triage over the last 18 months, you see what happens” – Patrick Radden Keefe

He is optimistic that things will be different 10 years from now He is fundamentally an optimist about a lot of things and has to believe we will learn and will find a way out of this
He is fundamentally an optimist about a lot of things and has to believe we will learn and will find a way out of this

Risk of relapse

One of the hardest thing is conversations with patients or family members who actually managed to stop using and seemed as though they’d moved on, and then went to a party
Relapse is such an issue with these drugs
When he talks to people who’ve achieved and found their way out of the woods, often the thing that’s so striking to is the sense of fragility to it They’re always talking in the present tense There’s the sense that every day is a battle
This worries him, the idea of 10 years from now, on a very micro level, the individual who is struggling with addiction
They’re always talking in the present tense
There’s the sense that every day is a battle

“There’s that sense in which it’s each tentative step, you just never know when you’re going to get pulled back in. On a macro level, nationally, I worry that there may be a similar danger.” – Patrick Radden Keefe

Similarly, Peter worries about what it takes to escape the gravitational pull of an environment that facilitated use of this drug
He recalls during heroin use in inner city Baltimore 20 years ago, when he was in his residency at Hopkins This was probably a leading indicator for how bad heroin use could get The hospital he was at would take care of a lot of patients who had abscesses and all sorts of infections and cellulitis and things like that from IV drug use Sometimes these infections themselves were life-threatening It wasn’t just the overdose on the drug; it was the repeated use of a dirty needle, or a needle that gets broken inside the arm and gets infected He would take care of these patients, and he always wished them the best when they left, but in the back of his mind, he knew he was going to see them again Even though for the 5 days that they were in the hospital, they were not using any drug, and they realized how lucky they were to get this second chance, they were still going back into the same environment that brought them into the hospital in the first place. Peter and his colleagues used to say to themselves, “ The only way this person’s not coming back is if they get a whole new group of friends. In fact, the best thing you could do for this person is get them out of inner city Baltimore. They can’t go back to the row home they came from. “
Now inner city Baltimore might sound like a very extreme example, with crack houses etc.
But is it really any different for a college kid, who’s trying to, desperately, get off the transition from oxycodone to fentanyl? This is being done in a dorm room or at a party or something like that; and it’s their friends, and they managed to pull out of the grip of that, but they find themselves at another party in three months It’s really difficult; that’s the part that is concerning
It’s hard to do this one person at a time
Patrick comes back to the idea of undertow, even as Peter was telling his own story of his experience with OxyContin
This was probably a leading indicator for how bad heroin use could get
The hospital he was at would take care of a lot of patients who had abscesses and all sorts of infections and cellulitis and things like that from IV drug use
Sometimes these infections themselves were life-threatening
It wasn’t just the overdose on the drug; it was the repeated use of a dirty needle, or a needle that gets broken inside the arm and gets infected
He would take care of these patients, and he always wished them the best when they left, but in the back of his mind, he knew he was going to see them again Even though for the 5 days that they were in the hospital, they were not using any drug, and they realized how lucky they were to get this second chance, they were still going back into the same environment that brought them into the hospital in the first place.
Peter and his colleagues used to say to themselves, “ The only way this person’s not coming back is if they get a whole new group of friends. In fact, the best thing you could do for this person is get them out of inner city Baltimore. They can’t go back to the row home they came from. “
Even though for the 5 days that they were in the hospital, they were not using any drug, and they realized how lucky they were to get this second chance, they were still going back into the same environment that brought them into the hospital in the first place.
This is being done in a dorm room or at a party or something like that; and it’s their friends, and they managed to pull out of the grip of that, but they find themselves at another party in three months
It’s really difficult; that’s the part that is concerning

“I think the big thing that comes home to me is just that these substances, they have an awesome power, and that’s compounded by all of the atmospheric, social, situational things you’re talking about” – Patrick Radden Keefe

He’s talked to a lot of families through the years, who’ve dealt with this, and they thought they were out of the woods, and then they weren’t
He thinks Peter is right; in any one individual life, and even somebody who actually has a whole support system there, and there are resources to treat the problem, it’s not enough; it’s not adequate On the flip side, in many instances, there are people who don’t have the resources for the appropriate treatment
He just thinks we should all be humble and mindful in the face of the tremendous potency and power that’s on the other side of this problem
Peter is thankful for Patrick’s book It has brought to light a lot of things that probably could have easily gotten ignored or swept away It’s true that during these proceedings, a lot of documents are brought into the public light, but that’s only half the battle; that’s the easy half The hard part is actually going through them and extracting what the story is, and Patrick has done a better job of that, with respect to this important part of the story, than anybody else
On the flip side, in many instances, there are people who don’t have the resources for the appropriate treatment
It has brought to light a lot of things that probably could have easily gotten ignored or swept away
It’s true that during these proceedings, a lot of documents are brought into the public light, but that’s only half the battle; that’s the easy half
The hard part is actually going through them and extracting what the story is, and Patrick has done a better job of that, with respect to this important part of the story, than anybody else

Selected Links / Related Material

Patrick’s recent book on the opioid epidemic : Empire of Pain: The Secret History of the Sackler Dynasty by Patrick Radden Keefe (2021)

HBO documentary on the opioid epidemic : The Crime of the Century | hbo.com | [1:15]

Patrick’s article about legalization of cannabis in Washington state : Buzzkill: Washington State discovers that it’s not so easy to create a legal marijuana economy | Patrick Radden Keefe, The New Yorker (Nov. 18, 2013) | [4:30]

Patrick’s article about the Sinaloa drug cartel : Cocaine Incorporated | Patrick Radden Keefe, The New York Times Magazine (June 15, 2012) | [5:00]

Recent article in Mother Jones about the AMA and Richard Sackler : The Untold Story of Purdue Pharma’s Cozy Relationship With the American Medical Association: The prestigious doctor’s group has made it virtually impossible to discern where public health guidance ends and industry interests begin. | Julia Lurie, Mother Jones (August 5, 2021) | [1:13:45]

Sam Quinones’ book about the Opiate epidemic: Dreamland : The True Tale of America’s Opiate Epidemic | by Sam Quinones (April 21, 2015) | [1:40:00]

Patrick’s podcast about the strange convergence of espionage and pop music during the Cold War : WIND OF CHANGE | host Patrick Radden Keefe, patrickraddenkeefe.com

Patrick’s website : Patrick Radden Keefe

People Mentioned

Chapo Guzmán (former leader of the Sinaloa drug cartel) [5:15]
Arthur Sackler (eldest of 3 brothers) [11:45; 18:00; 29:30; 1:10:00]
Raymond Saclker (one of 3 brothers) [11:45]
Mortimer Sackler (one of 3 brothers) [11:45; 1:40:15]
Richard Sackler (son of Raymond Sackler and Purdue Pharma executive) [27:15; 32:00; 41:45; 1:05:15; 1:13:45]
Sean Mackey (doctor at Stanford who helped Peter with pain when he quit taking OxyContin) [1:07:15]
Mary Jo White (former US attorney for the Southern district of New York) [1:18:45; 1:20:30; 1:24:45]
Senators and congressman involved in bills that supported OxyContin [1:19:30] Chris Dodd , Marsha Blackburn , Tom Marino , and Orrin Hatch
Rudy Giuliani (previous US Associate Attorney General) [1:20:30; 1:24:45]
George W. Bush (43rd US President) [1:24:45]
Alice Fisher (former Assistant Attorney General in the Department of Justice Criminal Division) [1:25:00]
Paul McNulty (former Deputy Attorney General) [1:25:00]
John Kapoor (CEO of Insys Therapeutics who was sentenced to prison) [1:34:15]
OJ Simpson (former football player tried for the murder of his wife Nicole Brown Simpson) [1:35:30]
Sam Quinones (Author of Dreamland ) [1:40:00]
Chris Dodd , Marsha Blackburn , Tom Marino , and Orrin Hatch

Patrick grew up in Dorchester, Massachusetts and went to college at Columbia. He received masters degrees from Cambridge University and the London School of Economics, and a JD from Yale Law School. He is the recipient of a Guggenheim fellowship, and fellowships from the Rockefeller Foundation, the New America Foundation, the Woodrow Wilson International Center for Scholars, and the Cullman Center for Scholars and Writers at the New York Public Library.

Patrick is an investigative journalist and has written extensively for many publications. He is an award-winning staff writer at The New Yorker magazine. His work has appeared in The New York Review of Books , The New York Times Magazine , Slate , and other publications. He received the National Magazine Award for Feature Writing in 2014, and was a finalist for the National Magazine Award for Reporting in 2015 and 2016.

He is the author of four books: Chatter , The Snakehead , Say Nothing , and Empire of Pain . Say Nothing received the National Book Critics Circle Award for Nonfiction, the Orwell Prize for Political Writing, and was selected by Entertainment Weekly as one of the “10 Best Nonfiction Books of the Decade.” The Rolling Stone describes Keefe as “ an obsessive reporter and researcher, a master of narrative nonfiction ”.

Patrick is also the writer and host of WIND OF CHANGE , an 8-part podcast series from Pineapple Street Studios, Crooked Media and Spotify, which investigates the strange convergence of espionage and pop music during the Cold War and was named the #1 podcast of 2020 by The Guardian . [ patrickraddenkeefe.com ]

Transcript

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