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

Episode Date: December 6, 2021

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. We discuss: Patrick’s investigation into distribution and use of drugs in our society [3:55]; The scale 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. Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/PatrickRaddenKeefe  Subscribe to receive exclusive subscriber-only content:  https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the drive podcast. I'm your host, Peter Attia. This podcast, my website, and my weekly newsletter all focus on the goal of translating the science of longevity into something accessible for everyone. Our goal is to provide the best content in health and wellness, full stop. And we've assembled a great team of analysts to make this happen. If you enjoy this podcast, we've created a membership program that brings you far more in-depth content if you want to take your knowledge of this space to the next level. At the end of this episode, I'll explain what those benefits are, or if you want to learn more now, head over to peteratiamd.com forward slash subscribe.

Now, without further delay, here's today's episode. My guest this week is Patrick Radden Keefe. Patrick is 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. The title of that book is Empire of Pain, The Secret History of the Sackler Dynasty. I've been wanting to do a podcast on the opioid epidemic for some time, and I've been trying to think of the right way to do it. Recently, I saw the HBO documentary, The Crime of the Century, and I thought it was a really good and thorough overview of the problem. Now, 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 then, of course, 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, and even the medical advocacy groups that provide guidance to physicians about them. When you consider the landscape of this problem and all of the actors that I just went through, you come to realize that every one of them plays some role in the situation we're in now,

the situation where basically half a million people have died in the past 25 years from opioid overdose and where opioid overdose now represents the leading cause of accidental death in the United States ahead of car accidents, gunshots, things like that. What Patrick's book does is go straight to the heart of the matter. How did this begin? What was the thin end of the wedge that created this epidemic? And he makes a very compelling case that it was the company Purdue Pharma, a privately held company run by the Sackler family. In this episode, we talk at great length about the history of the Purdue Pharma company and its management team. We talk about the implicit and sometimes explicit corruption that existed. And we talk about the other players in this channel, the physicians,

the regulators, the politicians, again, none of whom really get off scot-free in this assessment. This is a bit of a depressing episode. I'm not going to lie to you. I don't think we come away from this with an enormous sense of optimism that this solution is in hand and that five years from now, we'll look back at this and marvel at how easily it was able to be solved. I personally don't have a great sense of how that's going to happen, but nevertheless, I feel it is important to at least expose and shed some light on how we got here. Without further delay, I hope you'll enjoy my conversation with Patrick Radden Keefe. Hey, Patrick, thank you so much for making time to sit down. I know

you've done a number of these interviews. And one of the things I always like to do is try to go places or at least deeper than maybe you've gone before. So we'll see if that can be accomplished. There's certainly no shortage of material here to dive into. But I guess I kind of want to start with a question that I know you've probably spoken about before, which is what drew you to this story? Because the depths that you've gone to to research your book have been certainly at the upper decile, I would suppose, of what an investigative journalist would do. It's great to be with you and happy to talk about how I came to this. I've 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 illicit, which drugs are illicit. I wrote a big piece a number of years ago about

the legalization of cannabis in Washington state. Very interested in this idea that, you know, you have this existing industry, this pot industry that's been around for decades with the stroke of a pen, you know, at midnight it's legalized. And what does that look like? How do you turn it into a taxed and regulated economy? And I had done a lot of writing on Mexican drug cartels. So I did a big piece actually before I was full-time at the New Yorker. I did a cover story for The New York Times Magazine back in 2012 about the Sinaloa drug cartel. And to give you a sense of context, I mean, at the time, I had to explain to the editors of The New York Times Magazine who Chapo Guzman was.

He was not a household name at all. And the idea there was I wanted to do sort of a Harvard Business School case study of a cartel. I wanted to look at it as a multi-billion dollar transnational commodities enterprise. I was really interested in how they diversified and how vertically integrated they were. And one of the questions that grew out of that research was, you saw at a certain point a surge in heroin. So they had different problems.

Sinaloa dealt in cocaine, marijuana, heroin, and methamphetamine. But after 2010, you start seeing more Mexican heroin, huge volumes of it coming across the border in ways that it hadn't been before into the US. And that was kind of a riddle that I started with, was this question of why this sudden uptick in heroin? And the answer was the opioid crisis. And so it was one of these funny things where I started out with an inquiry that was kind of solidly grounded in the realm of the illicit drug trade and found my way into the world

of the FDA-regulated legal drug trade with OxyContin and Purdue Pharma and sort of started looking into the origins of the opioid crisis and then discovered that this company Purdue was owned by the Sackler family. And that kind of blew my mind, the idea that this family that's quite well known for philanthropy had made such a huge fortune on this drug with such a controversial legacy. That was kind of the way in for me. I kind of drew on a piece of paper a long time ago when I was trying to get my mind around this, how many actors there were. The paper looked something like this, right? It started on the left and it had producers. I was talking about this not through the illicit chains. So you had sort of the pharma companies of which Purdue would be the champion of them.

And then you have the distributors or the intermediaries, the McKessons and the Cardinals of the world. I actually knew a lot about McKesson through a previous life. So I 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 your third actor. Your fourth actor then became the FDA in the approval process of CVSs of the world. So that became your third actor. Your fourth actor then became the FDA in the approval process of a drug and then the DEA around enforcement. You could even put those two in a bucket. You then have the regulators that create or the policymakers rather that create the policies that allow these entities to exist. And then you have the providers, people that write the prescriptions for these things, and ultimately you have the patients.

So that's maybe a bit of an oversimplification, but it gives you a sense of just how complicated this web is. Now, we're going to spend a lot of time talking about one entity within one of those buckets. So why do you think that that is a place for someone who's maybe listening to this podcast to get a pretty good sense of the magnitude of this problem, because I don't think anybody could with a straight face say there isn't a problem. You'll put some numbers to what that means. But it's interesting that perhaps the study of Purdue Pharma and the Sacklers, more than any other single entity in that entire chain that I explained,

could provide a greater context of what we're up against. Would you agree with that? I mean, I'm assuming you have a bias. Otherwise, you wouldn't have studied them so extensively. It's great that you lay it out with that much nuance, because that's the kind of nuance that often gets lost. So there's two things I'd say. I mean, one is a kind of observation that I would make as a writer and a journalist and somebody who writes books is I go where my interests lead me. I write stories that I think are interesting stories, interesting to me that I think are important, that I think would be interesting to readers. It's very, very often the case that I'll spend

a lot of time on something and the reaction that people have is, well, why did you pick this? Why didn't you write about this other thing? There's this other variable that's very important here. And I instinctively resist those types of questions because on some level, I feel as though it's my prerogative as a writer to pick the area that interests me and do it and hopefully do it well in a way that has some integrity. But I make no claim to suggesting this is the be all and end all. So in this case, if it's the opioid crisis, there would never be any suggestion that this is the only book you need to read on the opioid crisis. And to segue from that into the particulars here. So when we talk about the opioid crisis, we're talking about an incredibly complex public health crisis that unfolds over the course

of a quarter of a century. Today, the numbers are a little imprecise, but you have at least a half a million people who've died from opioid overdoses since the mid to late 1990s. By some estimates, you have two plus million Americans today struggling with an opioid use disorder of one sort or another. And when we talk about opioids, that's actually a kind of pretty capacious category, right? So it's regulated drugs like OxyContin, but it's also fentanyl that comes in from China or Mexico. It's heroin. And in fact, when you talk about the death toll today, I think the Sacklers certainly would be quick to say, today people are dying in very large numbers from heroin and fentanyl overdoses, not from OxyContin or indeed, you know, from most prescription painkillers, this problem has

kind of transitioned into an illicit drug problem. So why pick OxyContin? Why pick the Sacklers? In my view, you know, in part, because it's an interesting story, I'm interested in the fact that this was a family, family dynamics are interesting to me, in part because of the philanthropic legacy, because there's this kind of disconnect, or there was until recent years, between the reputation that the family had and what I would argue is the reality of their business. But most importantly, because I think OxyContin was sort of the, in the words of somebody who worked on the drug, was 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, and also to keep in your mind

the idea that absent OxyContin, we might not be where we are today. That it 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, a market which eventually migrated to illicit sources of supply. That would be the reason I'm sure we can talk about it in more detail. But I think there's kind of a special role that Purdue and the SAC was played, which is not for a second to suggest that there isn't blame with all those different buckets that you mentioned, because there absolutely is. Based on what I've read of your writing, you also seem very well informed about those other buckets. So I definitely want to make sure we touch on them, but there's no place to start where we're going to start. So let's start

with the three Sackler brothers. Take your pick of who you want to begin with, Arthur, Raymond, Mortimer. Who were these guys? What got them interested in pharmaceuticals? I mean, you have to start with Arthur. I think you've got these three brothers. They were the children of immigrants. Their parents had come over from Europe at the turn of the last century, settled in Brooklyn. They were Jewish. The parents didn't speak English really all that well initially. They spoke Yiddish in the home. They raised their kids to believe in a few things. I think to believe in education, kids to believe in a few things. I think to believe in education, to believe in meritocracy. There are these kind of very American, like, 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 really kind of make their mark on the country and the world. And they were right. So they raised these three brothers. Arthur later said that from the age of four, he knew he would be a doctor with a sense that you're all going to grow up, you're going to get educated, you're going to become physicians. And there was a sense that there was kind of nothing as prestigious and virtuous as being a doctor. I think there was a real veneration in this family for the role of the physician in society. And so the brothers grow up, but they also grow up against the backdrop of the Great Depression. There's a period where their father loses everything. And so there was

an expectation that you also have to go out there and hustle and make money and have jobs. And so all three brothers work multiple jobs. I'd say in the book of 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. And that actually starts back in high school. When Arthur Sackler's in high school, he gets jobs on the student publications. He's at this huge high school, Erasmus Hall High School, at something like 6,000 or 7,000 students in Brooklyn, in Flatbush. It's still there today. He gets jobs on the student magazine, the student newspaper, but he becomes the advertising manager.

And if you think about it, you have 6,000 or 7,000 students that you can reach. That was a real job. And so that's where the hustle starts with Arthur. And all three brothers end up training as psychiatrists, practicing as psychiatrists, but they pretty quickly pivot into commerce. So what were the types of drugs of that era that were really making a difference in their practice. It seems that sedatives were potentially becoming of interest in that era. You have this kind of early amazing moment. There's this pattern that asserts itself with the brothers where Arthur goes and he does something, and then he kind of brings his brothers in with him. That starts in high school. He's got more

jobs than he can handle, so he starts handing them off to the brothers. And he ends up at the Creedmoor Psychiatric Hospital, which is a huge asylum, vast kind of industrial asylum in Queens, New York, public state mental hospital. With a staggering capacity, right? It's something like 6,000 beds. When I read that, I thought, that can't be possible. I don't know what that would look like. I literally can't picture the infrastructure large enough to have 6,000 inpatient beds. Yeah. I mean, it was a vast facility. I believe it was a facility designed for 4,000 beds.

You know, it's interesting because in these years, this is pre-Thorazine. It's like the last maximalist phase of big state mental hospitals, people basically being warehoused for life in these facilities. It's just prior to the deinstitutionalization that happens in the decades that follow. And so the brothers get there and they're shocked by the conditions. And also, if you think about it, I mean, Arthur in particular, he was a Freudian, he trained us at Freudian, right? So not a lot of talk therapy happening at a 6,000 bed hospital. Were they still doing lobotomies and things like that? They were.

I mean, in fact, lobotomies start up during this time. It's a lot of electroshock treatment and then lobotomies. And I should say, I mean, electroshock has its defenders even today. It is very successful for some people in some circumstances. But the Sackler brothers are there, and they're administering it thousands of times. And I think it just 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 that point, this theory that a lot of the afflictions they're seeing probably have some basis that is fundamentally chemical. And if that's the case, then there's probably some chemical solution. The brothers don't have anything to do with Thorazine, but when it comes along,

they see that. And this is in some ways a kind of glimpse of the future that they had envisioned. And it was, I think, generally speaking, an exciting time in the pharma business. You have penicillin, this huge game changer in the Second World War. And then 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 you just get 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. And consumers are, they're 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. It's in that exciting, I think quite idealistic whirlwind climate that the Sackler brothers come of age. Where did Purdue Pharma come from? Was it a company that they founded? Was it something that they bought and later transformed? It was the latter. Its origins date back to the 19th century. It was a little patent medicine company based, funnily enough, on Christopher Street in Greenwich Village, which is like, you can go to the building that it once occupied.

It's just funny that what had once been the humble Purdue Frederick factory is like 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. He really makes his name by joining and then taking over a pharmaceutical advertising firm. And he's a genius for advertising drugs at this 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, and he basically gives it to his brothers. So he remains, he's a stakeholder in the company. He

owns a third of it, but he's a silent partner basically. And the brothers will run the company starting in 52. And what happens over the next 30 years? Purdue Frederick is a very successful company. I mean, the brothers get rich, but they're getting rich in a way that is, I think that even Arthur would probably have sniffed at. Because Arthur, who, again, is one of the owners of the company. He's really focusing on the marketing of pharmaceuticals. His big success is, I mean, he had many successes, but his biggest success is that he designs the marketing and advertising strategy for the minor tranquilizer, Librium, and then for Valium, both of which Roche develops. And Librium becomes the biggest selling drug in

the history of the pharmaceutical industry. And then it's surpassed only by Valium. And 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. And Arthur designed all the advertising and the marketing for that. And 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. His brothers, meanwhile, what they're doing is less cutting edge. They basically license over-the-counter products and then sell them. And they were really smart about it. So 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 kind of battlefield applications in Vietnam. They had a laxative, Seneca, very successful. These are these kind of cash crop products. They're very unglamorous, but they're staples, over-the-counter stuff, but year in, year out, very, very successful. The irony, by the way, of the company that would create the opioid boom having a laxative, which is, of course, there to address one of the most painful short-term consequences of opioid use, being constipation. Well, and the crazy thing is that eventually it gets to a point where the sales reps for Purdue would go out and they'd market the one with the other.

They would market them together. But it's really only in the 80s that the company starts getting more late 70s, early 80s. The company starts getting aggressive about really investing in R&D, developing its own prescription drugs. And it's at that point that they move into pain management. Any inclination from your research why they decided to keep this company private as opposed to take it public like many of the large pharma companies? I can only speculate. But the Sacklers had a real sense, I think, for a long time that this was a old world enterprise, that it was a family business.

It was family owned, physician owned, they would always say. 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 becomes this multi-billion dollar company up to that point. It was a pretty modest outfit. The Stackler brothers themselves did really well. They were very wealthy, but it was a kind of manageable family firm. And I think that there was something to that. I don't know what it would have looked like if it went public. I do know that you've kind of put your finger on something there, because I think when you

get 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. That's the revisionist history in me, which is saying like, had they been a public company, how far would this have gone? Yeah. I mean, I don't mean to suggest that. I think in the early going, we can sort of get into the particulars, but there are these like hinge moments in this story. You've got all the stuff that happens prior to the introduction of OxyContin. And then you start seeing things go wrong and then they go more wrong. And it's like, well, how do you handle it when you see, how do you handle it when you start getting calls saying that the product that you sell

is killing people? And I think that probably would have been a different response in a public company. And then the really crazy thing is eventually we're getting ahead of ourselves here, but eventually you get a guilty plea in a federal criminal case in 2007. I think at a public company, if you had that, I just think heads would have rolled. You'd have a total change of personnel, big shakeup on the board. At a privately held family company, what happened was like- Pretty much nothing. Yeah. Yeah. Yeah. held family company, what happened was like... Pretty much nothing. Yeah. Yeah. Yeah. So talk a little bit about MS-Contin as the precursor to OxyContin and maybe the pharmacokinetics of it,

but more importantly, what that transition was about. In the 1980s, you saw, actually taking back to the 70s, a kind of revisionist school of physicians who felt in the UK and in the US and 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 were treating it just merely as a symptom, 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. And 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, that doctors have been too stingy in prescribing opioids for pain because of concerns about abuse and addiction.

And it's in this context that MS-Contin, this drug, is developed. And it's a cancer drug. It's a drug for cancer pain. And it's basically just morphine. But the real innovation was the Contin part. So Contin, short for continuous, it's essentially the coating on the pill. And the idea is that this will regulate the flow of the drug into the bloodstream over the course of hours. MS-Contra 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. I don't remember exactly what it was generating in terms of revenue at its height, but through $400 million a year, which was a lot for Purdue at the time,

it was a big success. And I think the family was proud of it. There was a sense that they were doing a good thing, relieving terrible pain for people suffering from cancer and doing very well financially. And so they were 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. And you had this interesting, and I don't think necessarily altogether cynical, confluence of interests in which Purdue starts sponsoring academic conferences on the treatment of pain and medical conferences and seminars. And they're sort of out there with an obvious commercial interest, but also I think a sense that we're part of out there with an obvious commercial interest, but also, I think, a sense that we're part of a revolution here. We're going to revolutionize the way in which pain is treated. Whose idea is OxyContin? I mean, in some sense, it's 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-released format. So was there great innovation basically saying, we're just going to make a time-release version of hydrocodone just as it had been done with morphine? Was that effectively the aha moment? Something I should say, and this will be not a surprise to you, but to me coming from the outside, I was really startled. I knew as a kind of objective analytical matter that the life cycle of a patent is very important to a drug company. 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 my reporting for this story where there'd be some sort of mystery about motivation. There'd be some weird thing that they did and I couldn't figure out why. And I would puzzle over it and puzzle over it and puzzle over it. And then it always turned out to be something having to do with a patent. For example, the pediatric indication? The pediatric indication, very 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 and I couldn't figure out why. And they had all these explanations that turned out to not be true. And then 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 realize that it's going to decimate their profits. And so they just start talking about, hey, what else could we put with the content system? And the family dynamics here are a little humorous, but there's, according to Kathy Sackler, who's one of the second generation Sacklers who's involved in the company and is a medical doctor, she has dinner with Richard Sackler, who's one of the second generation Sacklers who's 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. And oxycodone is stronger than both hydrocodone and morphine. It is. Part of what's interesting about oxycodone is that there's this amazing thing that happens basically where they make their decision, okay, we're going to use oxycodone. We'll develop OxyContin. There are these conversations that happen and they happen over email. And I have the 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, not a doctor, and your doctor tells you that your mother's going on morphine, that means your mother is going to die. And what they realize is that oxycodone didn't have those same associations, And what they realize is that oxycodone didn't have those same associations, even though it's stronger than morphine. They did focus groups. And you have oxycodone in Percocet and in Percodan. And that was the primary way in which physicians were encountering those drugs.

I misspoke earlier. I said it was hydrocodone. It's actually oxycodone. That's right. Yeah. And when they're cut with aspirin or acetaminophen, it's a relatively small dose. There's only so much you 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. There's a funny cartoon you could envision here, which is another revisionist, which is imagine if instead they just decided to figure out a way to make more cancer patients. Well, how could we do to increase the number of people dying of cancer to expand our market? And then

someone goes, no, no, no, no, that's too hard. That's too hard. I got a better idea. Let's just figure out a way to make everybody who doesn't have cancer takes this drug. Right. And in fact, to sort of create the need, which is a big part of what the marketing ended up being. Yeah. I mean, the analogy that I come back to, the first third of the book is devoted to Arthur Sackler in those earlier years. And that was a very deliberate choice, devoted to Arthur Sackler in those earlier years. And that was a very deliberate choice, even though Arthur Sackler dies in 87 before the introduction of OxyContin. Because I think there are all of these things that happen earlier that are kind of the seeds for what comes later. So the analogy I always think of is Thorazine, which the original Sackler brothers see. Thorazine is a major tranquilizer for people who are

psychotic. Very successful, emptied out the asylums pretty quickly. I mean, there were other things that did as well, but it was a real game changer. But there's only so many people who are actually required that kind of heavy duty solution. And then Arthur Sackler makes his fortune on the minor tranquilizers, where 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? And that 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. And you see these emails 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. So they developed this new drug. What's unusual about the process by which it receives its FDA approval? A handful of things.

We can insert Curtis Wright at any point here, by the way. Yeah, exactly. So 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, but also in order to get the marketing claims. Maybe explain to folks why those two things are very important. Why is it that if you and I went into business tomorrow to create a drug, the FDA would have to approve it from a safety and efficacy standpoint, but then they'd also

have to basically put guardrails around what we could actually say it's for. I don't think people fully understand that dual role there. It's the strangest thing. Richard Sackler, this second generation Sackler, is probably 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. It's a strange thing, right? Because I think for the average consumer, you see that dense wording on that and it feels like the fine print. It feels like something the doctors read. You may read it as well, but it doesn't feel like a marketing document. But if you're the drug company, it's all about the indications. It's all about the claims that

you can make for what kinds of ailments this medication might alleviate. And then also in terms of the competitive positioning. So in the case of OxyContin, I'll give you a very extreme example. They didn't do any tests on the you a very extreme example. 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. But there was a kind of hypothesis that they had at Purdue, which was because of the content system, you wouldn't have the kind of peaks and troughs, a sort of wave of euphoria when a big dose of the drug hits your bloodstream, followed by diminution and 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 that was a competitive advantage vis-a-vis other opioid products that were out there on the market. You have this kind of crazy stretch where they start working very closely with Curtis Wright on the approval process. Some strange stuff happens. I mean, the company said, I don't even think this is in the book, but the company sends Curtis Wright, this is in the 1990s, 1995. This is in the book, but the company sends Curtis Wright. This is in the 1990s, the 95. The company sends him a webcam.

This is like 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. And 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. Let's just pause there for a second. 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? What do you think emboldened the Sackler leadership to do that without fear of Curtis Wright turning to them and saying,

are you freaking crazy? How does this unfold? So it's really hard to say, and I've tried to puzzle through this. And I should say, I mean, Curtis Wright, I got him on the phone and he very quickly hung up. Didn't want to talk to me about any of this. I filed a Freedom of Information Act request with the FDA. They dragged their feet in the way that federal bureaucracies always do. So I sued them in federal court to compel them to turn over documents to me. And I got a New York federal judge to order them to do document production to me, thousands and thousands of pages of documents. And my first request was for all the emails of Curtis Wright. The FDA came back and told me that all of his correspondence and emails have either been lost or destroyed.

Yeah, which again, you couldn't make that level of malfeasance up. How do they even say that with a straight face? I could understand if it was a sort of a document retention thing where after a certain number of years, they eliminate stuff. In his case, though, this is a guy who had been, he was investigated by Department of Justice investigators really starting in like 2002, 2003. I mean, this was somebody who was red flagged early by other federal agencies. The notion that they would today say,

it's the equivalent of saying like, there was a very small warehouse fire. It's just that box, I'm afraid, that we didn't retain. It's pretty shocking to me. So I've tried to sort of puzzle this out. There's an interesting email chain. So 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.

This is as all of this approval stuff is happening. They talked in a kind of a sidebar way. It was not formal. You know, my sense is that generally speaking, the FDA process, at least in theory, is one that is pretty formalized, right? Because you don't want too much of an opportunity for improper influence to happen. And there's this interesting memo that the Purdue guy sends back to headquarters where he says, you know, 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. So I don't know. Wouldn't the Occam's razor response be the following. Given that a year after leaving the FDA,

Curtis Wright is now employed by Purdue Pharma. 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 Perdue and spent years poring over millions of pages of documents and looked really hard at Curtis Wright. He told me on the record, this guy is pretty careful about what he says. And he told me on the record, I think a deal was made. He said, I can't prove it, just my opinion. But I think a deal was made. When you look at the totality of the evidence, it seems hard for me to believe any other, I mean, he's

saying exactly what you are, any other explanation. I don't know that I need to go that far. And here's why. I don't think Purdue even needed to say, hey, make this work for us and there might be a job for you on the other side. And this is where, from a policy point of view, this gets really hard to regulate, right? Is that the FDA is full of overeducated, really smart people who are making government salaries, and 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 you 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, but also, I would argue, I think 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. And that's this 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. Because if you're the FDA,

what do you do? I mean, do you say, okay, we're going to have a cooling off period, you know, once you leave the agency, how long? A year? Three years? At what point do you start losing talent because people don't want to be locked up? 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. And I don't think it's unique to Curtis Wright. He's a very extreme example. But what you get is in his case, as you said, he goes a year after OxyContin is approved, he goes and works at Purdue for three times his government salary. To your 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. And that's a weird thing to have in a package insert

in general. It's a great marketing claim, but it's like is believed doesn't seem very scientific necessarily. What was the basis of that belief, the scientific basis? Was there a study that was cited? Was there an experiment that was done? I mean, it wouldn't be hard to have studied these things. There wasn't one. No. In this case, what it was was it was this conjecture that because of the content system, you're not getting the high highs and the low lows, and 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. So Curtis Wright has been asked about this and he said, oh yeah, it wasn't the FDA, it was Purdue Pharma. The Purdue Pharma officials

who were there say, oh, it wasn't us, it was Curtis Wright. But I mean, to me as a consumer, the idea that the FDA is working so closely with a drug company that literally you don't know where one ends and the other begins, and 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. Is it 96 when OxyContin hits the retail? Early 96, yeah. How long does it take before the unintended consequences, because there's really two unintended consequences here. I guess the first is people who probably would be better served with another form of pain control are instead using this drug. That would be one unintended consequence.

That's one that Purdue would not be against because that's simply more market share. And then there's the unintended consequence that everyone, including Purdue, would presumably not want, which is you start to kill your customers. Sort of the tobacco company problem, right? To have an addictive product with no termination of use is wonderful if you just could figure out a way to keep the customer alive. So what are the canaries in the coal mine with respect to these problems and how are they handled? I mean, I think in some ways it's probably useful to start with what the official story was, which is that the drugs 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 four years. There were four

blissful years where they got lots of letters from pain patients saying, you know, you've given me my life back. And there was no real sense at all that there was any kind of a problem. And it's only in early 2000 when the United States attorney for the state of Maine writes a letter to thousands of physicians saying this drug OxyContin is really dangerous, actually. It's killing people. People are overdosing. We've got a real problem here. And there's a crime problem associated with it. And a little bit after this time, the chief medical officer, Paul Goldenheim, the chief medical officer of Purdue Pharma, is brought in front of Congress, right? And he's asked questions about this. What does he say?

Same thing. He says, we had no inkling that there was any kind of big problem until this hinge point, which is when this U.S. attorney writes this letter in 2000. The other thing they say is that they say, oh, we read about it in the press. We read about these problems in the press. And for me as a journalist, this was funny because, you know, 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 of a company is doing 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.

There was something about their explanation that always seemed, just on its face, seemed a little fishy to me. When I dug into it, got a bunch of documentation, what I learned is it was a lie. They knew really early on. How bold-faced a lie was that? Let's use Goldenheim as a specific example. So in 2000, he's giving sworn testimony that we had no clue this was going on. What do his emails from the late 1990s suggest? That they did. You name it.

There's all kinds of back and forth about these drugs. There's another sort of associated lie that they told, which is that there had never been a problem with MS-Contin, which also is a lie, a lie that was told under oath, when in fact there's all kinds of back and forth about that. But you've got very, very senior people, including Goldenheim, emailing about the fact that there's an abuse problem, pharmacies are getting robbed, people talking 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, you know, nothing was said,

will be emailing about it. And then they'll say, should we have all this chat on email? You know, it's maybe not a good idea for us to be having these conversations on email. You have a very clear awareness that there's a problem. And if you back up for a second, part of the reason OxyContin did what it did, I would argue it changed the way in which these drugs are prescribed as a category of drugs, is that they had one of the biggest marketing forces ever. And they sent out hundreds of, something like 700 sales reps to fan out across the country, meeting with thousands and thousands of physicians.

That was how they kind of got the message of OxyContin out there. But those are the canaries in the coal mine. There's a story I tell in the book about a guy named Steve May, who was a Purdue sales rep in West Virginia. It's 99. So this is like before, according to Goldenheim, like they didn't know anything at this point. It's 99. Steve May had this one doctor. They're really big prescribers.

They would call them whales, to use the vernacular of a Vegas casino for a big gambler. Because if you had a big prescriber, that was great for your bonus if you were a sales rep. So Steve May had this whale. He went to call on her, which he would do from time to time. She's upset when he showed up and he asked her what the problem was. And she said she had a young relative, a young girl who just died of an OxyContin overdose.

So there you literally have an OxyContin sales rep going out and meeting with a doctor who's a big prescriber and finding out that her relative has died from an OxyContin overdose. And all those reps are writing these encounters up in notes and sending them back to headquarters. 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. I think from as early as 97. So that's just a year after the drug is released. And word is coming back into the company. And those discussions are not just happening at low levels. They're happening at high levels. I think what happens in 2000 is it just becomes impossible for them to deny it anymore. It's like at that point, the sort of head in the sand won't work as a strategy. So then you need to pivot. You need to say, okay, there is a problem. Here's our spin on it. And that spin, of course, became these are really bad people. We've created a miracle

breakthrough product that helps millions of people, but there are these derelicts who abuse this product and are jeopardizing it for everybody else. We really need to ramp up the enforcement of those people. What was proposed as the remediation for the problem? It was a bunch of things, all of which were very much along the lines of what you're talking about. The suggestion was there's nothing intrinsically dangerous about the drug. I should say the level of denial here is pretty impressive. But I mean, the Sacklers, even today, argue that instances of iatrogenic addiction to OxyContin, where it's

prescribed to you by a doctor for a legitimate condition and you take it as instructed by the physician, are vanishingly rare. That's like a block that they have where they can't really acknowledge even today. Now, do we know what that true number is? If we say, and I'm being a bit perhaps overly simplistic, so feel free to make this more realistic. But if we say there are three buckets in which a patient came across OxyContin, bucket one would be, and this excludes the cancer patient. So I want to take the end of life cancer patient out of the equation for a moment. So if you talk about patients who are not terminally ill, who have become exposed to and or addicted to OxyContin, entry path number one is the individual who is recovering from surgery. They are by their actual doctor, who is a legitimate doctor given a prescription

for a reasonable quantity of OxyContin that should get them through the perioperative period. Path number two is, by the way, you can get to path number two from path number one. So these are not independent paths, but path number two is the sham doctor, the doc in the box who's prescribing this stuff from one state when you're in another state, doing it online or running basically the revolving door clinic where you just come in, you ask for what you want, you get a prescription, you go out the door provided you fill it at a pharmacy a couple hundred miles away. So they're a doctor only in legal terms, but they're certainly not a physician in any reasonable sense of the word. And then path number three is the illicit acquisition of OxyContin through a stolen

channel. So much in the same way you would buy any illegal drug, you're simply buying OxyContin. a stolen channel. So much in the same way you would buy any illegal drug, you're simply buying OxyContin. Do we have a sense of the relative distribution of paths one, two, and three? No, it's very hard and in fact, impossible to parse it out. And I also think it's something that's fluctuated a lot over time, but you do get these little data points that I think are illuminating. And I'll give you two. These are honestly like two of the more shocking things I discovered in my research, but it's hard because it's a little complex. And so sometimes I think from the cheap seats, it's like hard to appreciate the gravity of this. So Purdue sells OxyContin, they release it in 96. Right away, people realize that that contenseal, you can override that just by crushing the pills. So you can chew them, you can grind the

pill, you can dissolve it in water after you've grinded and shoot it if you want intravenously. There's actually a warning on the models telling you not to crush the pills because if you do, you could get a potentially toxic dose of oxycodone. So in a weird way, that functions as a kind of inadvertent how-to. I think that's significant for at least maybe for all three of the buckets you're talking about, because you get people who are just opportunistic drug users looking to get high. I certainly have interviewed a lot of people who say that heroin was scary. You bought it on the street. You shoot it with a needle, that they were looking to get high. It was like a party drug in high school, OxyContin was,

but there was something reassuring about the fact that it had been approved by the FDA. You know that even if you bought it from a dealer, at some point, this entered the stream of commerce. There was a doctor writing a prescription. You also have 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. And 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 is what they'll say. So you get different ways of getting there, but the pill can be crushed. That's 96. In 2010,

Purdue rolls out this reformulated version of OxyContin that they've worked on for years. It's basically, you can't crush it. It's like a gummy bear. If you try and break it up, it just kind of goes chewy and gummy on you. There's an interesting backstory there, questions about why it took so long to roll that out. There's an interesting aspect of the timing, which is that the original patent on OxyContin were about to run out. So just in the nick of time, they have this line extension basically in the form of the reformulated drug. Well, it goes one better than that, doesn't it, Patrick? Because 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. I mean, again, that would be the skeptical view of things. And I think in this case, the skeptical view is right on. And in fact, 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, that that was the reason they were doing it primarily was to extend the patent life.

The surpassing cynicism of the idea that having for at that point 14 years said, oh, it's perfectly safe, it's perfectly safe, it's perfectly safe, the original formulation. They develop their new formulation and then they turn around and say, but we wouldn't want to see any generic versions of the original formulation because in fact, it's perfectly safe, it's perfectly safe, the original formulation. They develop their new formulation, and then they turn around and say, but 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. And it worked, and the FDA obliged. But so here's the statistic that really blows my mind. 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. And what I discovered was a study, an internal study that found that in 2010 when this happened,

for the 80 milligram pills, which was the biggest and most profitable pills on the market, also the most popular on the black market, sales nationwide fell 25%. I can't tell you proportionately who's in what bucket. What I 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, which is astonishing to me because 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, like the black market was helping to pay the bills at the company.

The thing that I really wish we could have an insight into is even if you take the most charitable view of things, which is that every person's first interaction with OxyContin was through path one, that is to say you were legitimately prescribed this for non-cancer pain by a legitimate, caring, understanding physician. But then a subset of the people left bucket one for bucket two or bucket three as their appetite for the drug grew in the absence of an indication versus how many people de novo show up in bucket two and bucket three drug seeking. The fact that we don't know that makes this very difficult and creates this moral ambiguity around it, which frankly is a bit of a

distraction from the real culpability here. Oh, that's interesting. I mean, I think the fact that we don't know it and that it's impossible to know, combined with the fact that when you look at, this is a favorite of Purdue and the Sacklers, but 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. There's this whole exercise of parsing, like moral and legal parsing that they do, which I have to say for me, just as someone who's trying to live a righteous life, it's always amazing to me because I always just think, I can't imagine, how do you get there? At a certain point, so many people have died from your product. It's this kind of incredible symphony of rationalization that happens.

On your point about everybody, ideally, you'd have a situation which everybody sort of enters through bucket one. Let me give you the other statistic, which is that we'll get to this, but 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. And one of them is UnitedHealth. UnitedHealth had this fascinating filing where they were talking about the idea that they should have a piece of the pie, such as it is. And we'll 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 they said they ran a study. I don't remember how many years it was, but it was over the course of

something like seven or eight years. They looked at people who had UnitedHealth plans and who were prescribed OxyContin or another Purdue opioid and subsequently diagnosed with an opioid use disorder. I think that would actually be a kind of a smaller subset because you literally have a diagnosis of an OUD. And they said that for that subset, prescription from a doctor, subsequent diagnosis, just UnitedHealth over seven or eight years. They said the number was in the hundreds of thousands. I mean, I'm sure it would be in the study, but what percentage of people was that who were initially given a prescription? Was that 10%, 20%, 50%?

Oh, that I don't know. That's interesting. I don't know. It probably was. It was not revealed in the filing to the bankruptcy court. That would be interesting because that would actually shed great light on this issue. It would. The thing that's interesting is that it remains a talking point, certainly for the Sacklers and their legal counsel, that it's virtually impossible if

you're a pain patient and you're prescribed the drug by a doctor and you take it as directed to become addicted. To put that side by side with this hundreds of thousands number is extraordinary. Even if you build in a discount where you say, okay, well, some of those people probably did, you know, some of those were fraudulent docs or fraudulent patients or what have you, you still end up with a really huge number of people who have become hooked on the drug in an iatrogenic context. You know, I have a real personal history with this, which I'm sure you'll appreciate. I wasn't sure I was going to personal history with this, which I'm sure you'll appreciate. I wasn't sure I was going to tell you this story, but I think it's appropriate here.

In some ways, I feel very lucky to be sitting here having a discussion right now as opposed to being dead. A little over 20 years ago when I was in my last year of medical school, I had a really bad back injury. I sort of hurt it kind of acutely and for two and a half weeks, just ignored it. But the pain grew more and more debilitating. I remember I was doing a rotation. I couldn't even sleep. I had to get the residents to inject Tordal into my thighs just to allow me to have enough of an inkling to be able to sleep for a while. Finally, at some point, I just agreed to go get an MRI and look. And sure enough, there was a really bad herniation in my lower back and about a five centimeter fragment of disc had broken off on the left side and it floated down the canal and it was sitting

on the S1 nerve root, which is what was causing this almost comical amount of pain. I say comical now because it's hard to even describe. There's nothing funny about it. So I underwent surgery the next day, but surgery didn't go well for a number of reasons, but the surgeon operated on the wrong side. So I woke up from the surgery in terrible pain, but also with a new complication on the other side. This resulted in a number of follow-up procedures initially aimed at correcting the first problem. But before I knew it, even once the structural problem had been fixed, the pain was so bad that I finally relented and agreed to take pain medicine. I had been horribly petrified of taking anything beyond NSAIDs. So what was the first drug? This is the year 2000. So what's the first prescription I get? It's for 20 milligrams of OxyContin to be taken, I believe,

twice a day. I think you take 20 in the morning and 20 in the afternoon or evening or something like that. You can probably imagine where this story is going, Patrick. How much OxyContin do you think I was taking within four months? Tell me. Almost 400 milligrams a day. So again, maybe 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'd just stop breathing. So it didn't take long for me to go from 40 milligrams a day to 400 milligrams a day. And there are a couple of things about this that are interesting. The first is that was all prescribed by a legitimate doctor who was not at all an expert in pain management. This was a surgeon who had already

demonstrated gross incompetence in not operating on the right side. No one was monitoring how much of this drug I needed. The dose just kept going up and up and up. I was very fortunate at the time to be dating an anesthesiology resident. So she was about three or four years older than me, actually probably in her last year of anesthesia. And she herself was actually interested in pain management. So she would go on to do a fellowship in pain management. She was a bit troubled by how much of this drug that I was on. And that sort of got me thinking, how the hell did I get here? Because it happened so quick. 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 that I wasn't high.

The turning point for me came when I realized that I couldn't differentiate between the pain relief and the high. In other words, I realized I was probably taking the drug to avoid the psychological pain, which at the time I was pretty convinced I'd never walk again. This was a one-year recovery process, but the first three months I couldn't walk. That basically shattered all of my dreams. I was no longer going to be able to be a surgeon. I believed, let alone be an active, healthy person that I'd been all my life. And so I was actually taking this drug just as much to blunt that grief as I was taking it to blunt the pain. And finally, in the fall of that year, I just decided I don't want to do this

anymore. I never imagined I would overdose. That's the other thing, by the way. It never even crossed my mind that I could get to a point where I would stop breathing. But I just thought, no, I can't do this anymore. So I said to my girlfriend, I said, I'm going to stop this cold turkey. And she said, 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. I mean, she rattled off all the drugs I would need to take to taper off. But I was a stubborn kid and I just stopped cold turkey. And the next three weeks of my life would be about the most miserable three weeks of my existence. I certainly hope I don't have another three weeks somewhere down my life that will be that bad. But here's

the thing that is interesting. I'm not telling this story to for a moment suggest, suggest any superiority. Like, look at me, I was able to come off this drug. What my point is that what I've learned about addiction since then would suggest that I'm simply biologically lucky. In other words, I truly believe that the neurotransmitters in my brain are not wired the way that someone who in that exact situation would have become a lifelong addict. That's why I say I'm very lucky. I'm not lucky because I have willpower. I'm lucky because that chemical didn't put a hook in me the way it would in others. So in other words, I had become physiologically dependent on it. And that's why I went through withdrawal just as anybody would.

But I'm really lucky I managed to escape this drug. It's interesting. I was still deathly afraid of the drug after the fact. Only seven years later, when I had a really, really bad dental issue, would I ever touch another Percocet in my life, which of course is a fraction of the drug. And I remember being really worried, like, what's going to happen? Is this going to escalate into massive use? And fortunately it didn't. I needed Percocet for like a week until I had a tooth extracted. I just stopped it and that was fine. It paradoxically gave me more empathy than self-righteousness over the people who became addicted. I don't know why. That's not obvious why that would be the case. I think I just sort of believed that there are some of us who don't get addicted to these things, even when exposed,

but there are enough people who do. And I don't know what that number is, right? And to your point, I don't know that we can ever know that number. But I agree with you that that doesn't remove the moral obligation of the people that were involved in exposing people like me and people much less fortunate than me. I would imagine that part of the reason that it gave you a sense of compassion for those whose experience has turned out much worse is that it does sound as though you encountered,

and I've 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 that you're suddenly in the grip of something. You managed to get out of the grip, but it sounds like even you were in terms of the physiological dependence and the idea that you were titrating up so fast. That upward speed was unbelievable, Patrick. Unbelievable how quickly a tolerance developed. And by the way, it's total bullshit to say you don't get high from a time-release drug. I don't know what it's like to take heroin, so I'm sure compared to heroin, it's blunt. But there is an absolute blast-off high that came from those mega doses of that drug. What's so intriguing to me, though, about your

story is actually the doctor. The idea that you have a surgeon who writes you the prescription. And part of what's so fascinating is that the drug companies, Purdue and the other companies, argued from the beginning that doctors don't know enough about pain management. They haven't gotten the training. And there was some truth to that. But 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. The first part of that, right, is it's like,

this isn't some nuclear solution you keep on the top shelf where you would try other courses of therapy and only when those fail do you resort to it. It's the first thing you should administer. And then it's the one to stay with, meaning you can just keep taking it for chronic pain conditions year in, year out, even if you have to keep titrating up. And it was a core belief at the company, Richard Sackler felt very strongly about this, that there was no, what he described as no ceiling effect with OxyContin. That in fact, you could just keep taking greater and greater doses, which you would need to as your system accompanies itself to it. And then you have the pharmaceutical reps who are meeting with doctors

like your surgeon and are heavily incentivized to get those docs to titrate up. That's always the message because the profits, and in fact, even the bonuses for the pharma reps are all based on volume of the drug that's sold and prescribed. It's just funny because hearing your anecdote from your side, what I see on the other side is this sort of perfect storm of scenarios where when you're thinking about like, do I go cold turkey? Do I taper off? Should I be taking morphine? You're having those conversations with your girlfriend because the guy who prescribed you the drug probably doesn't know how to explain to people how to get them off. I mean, you have this crazy situation in which you have a generation of doctors who learn how to on-ramp their patients

with these drugs and never learn how to off-ramp them and actually kind of don't necessarily have any interest or inclination. And if you talk to people who've had these experiences, they'll say, I went back to the surgeon who wrote me the original script and I said, I'm having problems here. And they say, whoa, whoa, whoa, I'm not an addiction specialist. When you look at all those circumstances and you kind of extrapolate from that story you just told, it's not surprising to me to think that there are many, many, many people who had a similar situation and ended up in very dire straits. You made me think of something else, which I should have mentioned earlier, which is there's another reason I was very, very fortunate was to have a girlfriend at the time who is not just an

anesthesiologist, but someone who's a year away from doing a pain fellowship, she actually got me in to see a pain expert at Stanford who I think really is the guy that saved me. Because remember, it's one thing to sort of quit this drug cold turkey, but I still had pain. Getting off the drug was one problem, but addressing the pain was another., but addressing the pain was another. And I think only because of this other guy whose name was Sean Mackey, I don't even know if he's still at Stanford, but he was able to treat me, I think appropriately, right? So that meant doing a lot of injections to begin and sort of cool things off that had flared up

using a drug called Neurontin, which is not addictive, incredibly benign. It is sedating. So that's a drawback to deal with the neuropathic pain and then using very strong NSAIDs. So at the time Vioxx was a drug that basically saved me. And that allowed me to break the cycle of pain and do enough PT such that a year from when that whole thing began, I was actually in my surgical residency and free of all pain medication, meaning free of the Neurontin and free of the Vioxx. That part of the story also speaks to the incredible fortune that I had that many people don't have. And maybe had I not had it, there still would be a different ending, right? It still might've been that, well, after three months of going cold turkey, I had to go back because there was no alternative.

And when I was in my residency, I was still amazed at how ignorant we were as surgical residents of pain management. I mean, completely ignorant. There was absolutely no teaching of this subject matter. Something that I learned that was very simple was studies had demonstrated that before you do an incision on a patient, if you inject Marcane, which is a long acting sodium channel blocker, like a Novocaine type thing that the dentist would put in your teeth. So you have lidocaine, which is short acting, Marcane, which is long acting. If you inject the incision site with Marcane before you cut, wait a moment, you then make the incision, and then immediately following surgery, you put the patient on a pretty aggressive dose of NSAIDs. Many

patients can actually avoid narcotics postoperatively for the incisional pain, which is the dominant source of pain. And I remember thinking, why aren't we doing this with every patient? I got into an argument with one of the attendings because I was about to do an operation and I went to do this. And he said, come on, come on, come on. That's going to take five minutes. You've got to put that in and then we have to sit here and wait five minutes with our dicks in our hands while it sets in before you cut. No, no, no, no. We don't have the time for that. And I remember thinking, really? We don't have five minutes? You know, it was shocking. Yeah. I think in a weird way, I'm not a doctor, right? I say this coming from the outside,

but having done a little bit of an anthropological bushwhack through this world over the last few years, you go back to what we were talking about earlier, where you have the Sackler brothers in the 1940s and 50s saying, wouldn't it be beautiful if someday there was just a pill you could take for everything? And particularly Arthur Sackler kind of trying to sort of intermingle medicine and commerce in ways that I think ended up being more profound than anybody could have probably recognized at the time. From the outside, I think that one of the ingredients that gives you the opioid crisis is actually that idea of we want to waste five minutes. We need to get our patients in and out.

Time is money. And I've interviewed doctors who talk about how they felt duped, how when the Purdue sales reps started flogging OxyContin, if you're a doctor, you encounter patients who are in pain, you want to relieve that pain. It's often, in some ways, inherent to why you chose to do this in your life, right? You want to bring relief to people who are suffering. And suddenly there's this medical innovation, which you're 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. I've talked to people who've said, just earnestly, that was a siren song I was all too ready to listen to because it filled a need in my therapeutic arsenal. And of course, it ended up being more complicated. But I also think that when you think about the way in which American medicine

is structured, the idea that you have a patient who's in pain and you say, I'm going to write you a prescription for 20 milligrams of OxyContin, be on your way. I never have to see you again. I'm not really going to give any thought to how this is working out for you two weeks from now or two months from now or two years from now. I think that that notion that five minutes is money, that five minutes is five minutes you're not spending with the next patient. It's a longer line in the waiting room. I think those kinds of structural considerations were part of what allowed Purdue and other opioid makers to kind of snow the medical establishment as effectively as they did,

where if you look at the prescribing levels for these drugs, with the introduction of OxyContin, they just suddenly start climbing in this really dramatic way. And you would think that there would have been more skepticism, that it would have been slower growth. But I do think there was a sense in which it sort of filled a number of needs. And that was what allowed it to take off the way it did. Well, it also seemed to become very politically correct in the sense that they somehow managed to infiltrate the AMA. I mean, one of the other memories I have from the early days of residency was how all of a sudden a new vital sign emerged. So vital signs are by definition objective. So 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 got introduced, which was pain, a subjective measurement on a scale of one to 10. And 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. So how involved was Purdue in driving that agenda? I want to be careful about how I put this. Very would be the short answer, but I think you have this tricky thing. It's a little bit like when I was talking about Curtis Wright and the FDA and how there's a kind of soft corruption that happens, which is not as glaring as the

caricature-ish corruption that you would think of. I think there's a similar thing here where you have the American Medical Association, you have all kinds of groups, groups of doctors, groups representing patients, patients' rights, kind of pain advocacy groups. And then you have industry underwriting a lot of this stuff. Quite a good piece in Mother Jones just recently about the AMA and Richard Sackler was on one of these boards and you have a lot of money going to sponsor education. I just read that Mother Jones piece and I couldn't believe that the AMA, both as an organization and its foundation, separately are receiving money from the Sacklers. Yeah. And then often what happens, right, is that you get these things where it's like an

educational pamphlet that they end up distributing. There's a kind of laundering that happens, a sort of institutional laundering where industry comes up with these educational brochures, or they sponsor research, or what have you. I mean, the example that I love from that story, 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 that, remember, got 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, you know, that's not an option. I think it's more a coincidence of interests in which you have people who earnestly believe these things and then are underwritten by industry. And 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. When you talk about the idea of the fifth vital sign, even just that phrase, on the one hand, I think that there was some truth to the critique that there hadn't been enough education in pain management and enough consideration given to how you relieve patients' pain. I think as a critique, that had some truth to it. On the other hand, when you say the fifth vital sign, like to me, that sounds more than anything like a great marketing slogan.

I don't know who dreamed that up, but it sounds like something that an advertiser would come up with. It's catchy, it's kind of pithy, and of course, it's totally subjective. There was a study, I couldn't give you the citation, but I remember reading this great study where it was like the scale of one to 10 thing. What might be a seven for you could be a nine for me, but that it actually varies regionally. They found that

people in Northern Europe, you'd exert some sort of standard amount of pain and they would say, oh, that's a four. And then people in Southern Europe, you'd exert the same amount of pain and they would say, it's a 10, it's a 10. You actually get these cultural regional differences in terms of people's pain thresholds. It's hard because I do 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 I think that again and again, you see just the money pollute everything. You mentioned earlier that Curtis Wright effectively, whether in a direct quid pro quo or more of just a confluence of interests, not only basically approves this drug single-handedly for the FDA, but then ultimately winds up working for this entity.

But the other story in this one that really blew my mind was that of Lyndon Barber at the DEA. On the one hand, seems by all accounts to be one of the most credible voices within the DEA to standing up to the unmanaged distribution of these drugs, and then kind of doesn't about face and becomes one of the most powerful lobbying entities for the very companies. I believe Cardinal was one of his largest clients, Cardinal McKesson being two of the largest distributors, kind of hard to believe. But at the same time, I guess going through what you said earlier, it's like, look, how long can you work for nothing as a government employee? 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. I don't know how else to put it. It just doesn't sit well with me. I don't want to sound like a scold or preachy or somebody who's holier than thou or like a Boy Scout, because I'm not by any stretch. But it has been one of the more dispiriting things working on this project where, you know, a lot of the time in the past, I've written about crime a fair amount. It's just kind of baked in that you're writing about a bad person doing a bad thing. And they kind of know they're bad, usually. And there's a sort of moral clarity there. What was so fascinating to me about this story is that I think the Sacklers are bad actors. I think they did really bad things.

And they're the focus of the story. But then around them are all of these facilitators. And it's former prosecutors who go and work as private defense attorneys for the family or for the company. It's former DEA officials who go and work as lobbyists for the industry. It's former FDA officials who go and work at the company. It's folks at McKinsey. It's this whole kind of amazing entrenched machine of people who I think 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 my book is Mary Jo White, former U.S. Attorney for the Southern District of New York. She was Obama's head of the SEC, a woman who broke the glass ceiling. And she's represented Purdue and

the Sacklers for years and is totally a handmaiden to them. So it's a thing that I've kind of wrestled with personally. I'm a lawyer by training. And I know that there is a sort of, it's very fundamental to the ethos of the profession that the lawyer isn't the client and that we shouldn't necessarily transpose the moral stink of the client onto the lawyer. But it's hard for me when you tell the Lyndon Barber story, there's a hundred people like that in the book who play that kind of role again and again and again. You get these people who are supposed to be the cops, basically. They're supposed to be law and order, and they get

co-opted by the money. And it's really discouraging. And sometimes I don't get it because the money isn't even that much. I mean, when you look at Chris Dodd and Marsha Blackburn and Tom Marino and Orrin Hatch, I mean, it's just hard for me to look at these people and think of them as reasonable or respectable, truthfully, when I look at their involvement in the bills that they sponsored and the positions that they took in all of this. And when you look at the dollars that they received- They're bought so cheaply. Yeah, that's exactly the point, Patrick. I expected that it would have taken tens of millions to have bought those people. They were bought for hundreds of thousands of dollars. U.S. senators for sale for hundreds

of thousands of dollars? I don't understand it. So I think the thing is, some of it is the money, donations and what have you. But I think there's this other thing that is more about the revolving door, this insidious thing where the lobbyists, and the lobbyists are often people they know. You see this with the way in which Purdue and the Sacklers would use lawyers, like Mary Jo White is a good example, or they hired Rudy Giuliani for years, was kind of their hatchet man. And it's like, 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. I think when you look at these people, it's not just that they're, again, it's the sort of soft corruption. It's not like 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 sort of that. It's like being really smart and strategic about who's the right messenger. Who would we send to make the case to Chris Dodd

about why he shouldn't come after us or why he should help us in this or that? And they're really good, really, really good at that. And it's interesting at how, if I want to use the word, you might not use the word, but if I want to use the word corruption, how bipartisan the corruption was. What was the bill, H.R. 4709? This is the sleeper bill, right? It's like this three-page nothing burger that basically opened the pipelines to move these drugs and put the DAA's hands behind its back. I mean, it's a little detail, but my God, it's amazing how unopposed that bill went. Absolutely. But some of that, I think, is the fact that nobody's really reading the bill. The bill was carefully designed to look like it was sort of doing the opposite of what it was

doing, right? It's like, we're going to fight the opioid crisis. Obama signed it, and who knows how closely he looked at it. There's enough business that goes on in Washington. And I think particularly when it comes to lawmaking, you have these members of the House and senators who are, they spend all their time raising money. If you can make what you're doing look like business as usual, you can pull it off. It's super dispiriting. The opioid painkiller industry spends, I think the statistic is like seven or eight times what the gun lobby spends on lobbying in Washington. So just imagine the kind of impact that you can have on the legislative picture. And then you see this with a company like Purdue, you have this long period of time where all these states are trying to respond at a state level to the opioid crisis.

You know, they're trying to introduce new legislation to shut down pill mills or go after bad docs and what have you. You have these legislative initiatives at a state level that get set up and Purdue finds the right state lobbyists to go to the state capitol and help neuter those bills as best they can. And we're 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. What was the first shot across the bow, 2007? It's a little bit of a slap on the wrist. What led to that? You had a couple of investigators at a small

federal prosecutor's office in the Western District of Virginia. Their community had been upended by OxyContin specifically. They started realizing, you know, we're getting all these pharmacy thefts and crime is going up and you get people ODing. And they started investigating. And to them, it was this kind of weird thing where they felt like a hurricane had just like hit their town. They wondered where it came from. It came from Connecticut. So they started investigating and they did this really amazing investigation.

They spent five 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 being that these guys were not going to go to jail. Faced with jail time, they would flip on the Sacklers. One of those federal prosecutors has said this on the record, and there's another one who's confirmed for me that the plan was actually to target the Sacklers if they could flip these guys. And 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 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. So they got overruled by their own bosses. This was Alice Fisher and Paul McNulty? Yeah, exactly. It's a little bit like that line in the package insert where in 2021, I talked to Alice Fisher and Paul McNulty and said, who made that decision to tell these prosecutors in the Western District of Virginia? And it's like, they're each pointing at each other. They're pointing at each other. Nobody would own it. You would think all these years on, pretty consequential decision. You

would think that somebody might take responsibility for it. But what that meant is that because they couldn't charge these guys with felonies, the guys weren't going to flip. They pled to misdemeanors, so they couldn't go after the Sacklers. The company paid a $600 million fine and pled guilty to felony charges of misbranding. And then it was pretty much business as usual. I mean, they didn't slow down their marketing a jot. So what changed in the last couple of years? What's led to the bankruptcy? And perhaps more importantly, where do we stand on, what is it called, this non-consensual? Third-party release. Yeah. Third-party release. Yes. This seems to be a very important

granting on the part of one White Plains bankruptcy judge. So 2007, the company pleads 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. And 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. And 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.

So if you imagine, right, you have a company that pleads guilty in 2007, and then in theory, there's like 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. And in between those two guilty pleas, what happens is that you get all these lawsuits. So 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 the Sacklers, starting in 2007 after that guilty plea,

they start quietly taking money out of the company. So they're just sort of siphoning money out, $100 million here, $100 million there. Over the course of about a decade, they take more than $10 billion out of the company. 2018, 2019, you have thousands of lawsuits against the company. Company's kind of on the ropes. And the family kicks the company into bankruptcy. They say the company doesn't have any money anymore, which is only the case because they took $10 billion out of it. But they say the company's bankrupt now. So all those lawsuits

against the company have to be suspended. And they end up in this bankruptcy court in White Plains, New York. Because this is the way bankruptcy law works, they got to pick their judge. You can decide where you want to declare bankruptcy, corporate bankruptcy. So they picked this judge who they thought would be sympathetic. And where it gets really interesting is that 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 was a move by the company and the family to say, OK, 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 you're not able to do that. You're not able to say to the attorneys general of half of the states, no, you cannot bring your lawsuit. A federal bankruptcy judge in New York says to the state AG of Idaho, no, you cannot bring your state-based claim. It's pretty exotic, but he did. And where we are now is we're sort of in the end game where the Sacklers have made this bid, which is they want him to make that grant permanent, where he would permanently immunize them from any litigation. The phrase for this, and it's a mouthful, is non-consensual third-party

releases. This is happening in real time. As you and I are talking, there's a bankruptcy trial going on with testimony, but I think everybody knows how it's going to end. Why are we so pessimistic? Why are we pretty convinced that the ruling is going to hold up? Because the judge has kind of telegraphed where he's going with it. And because there are some states that continue to fight effectively don't have the votes. So basically what you have 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 non-consensual third-party releases, where basically this judge gets to wave 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. And I think 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 it's an interesting one because I think a lot of people look at it

and they feel like this wouldn't be justice. To put that $4.5 billion number in perspective, the Sacklers still have an $11 billion fortune and they're going to pay out the 4.5 over nine years. And it's actually not linearly weighted. The majority of that payment comes at the end of time. So in theory, they're technically going to come out ahead if they reasonably invest well. Yeah. I had some conversations with people who advise high net worth families and invest their fortunes in the conservatively between interests and a very conservative portfolio, they can probably expect a 5% return on that $11 billion fortune. And if that's the case, they never have to touch their principal. Yeah. In absolute terms, it's a lot of money, but it's, I don't think commensurate to the damage.

And I think ultimately it'll be a pretty good deal for the Sacklers. But I think that's how it's going to shake out. Now, do you think that this accomplishes anything else? So no amount of money is going to bring back a loved one. I have 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, if not a year, was at a party. Someone suggested he try a pill. It turned out to be laced with fentanyl. You know how that story ends tragically. So no amount of money is going to fix that. And so whether the Sacklers have to give four and a half billion or forfeit every dollar they've ever made and will make in perpetuity, that never brings back a life. So really it's about two things, isn't it? It's sort of about how much can be fixed today with

money, because maybe some things can be fixed with money, some things can't. I guess three things, is justice being served? And the third thing would be, is this creating a deterrent for another entity in the future to be a little more careful with what they do? Let's talk about the latter. Do you think that this will create a sufficient enough deterrent? And not just this. I mean, if you look at, what was that other company, Insys or something like that? Yeah. Insys was different because Insys, people went to jail. Yeah. So when you look at the totality of these things, do you think that at least for the foreseeable future, the legal slash illicit drug market is on notice? I do and I don't. Look,

in some ways this fits into a larger trend that we've seen 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. So you have this kind of bizarre thing with Purdue Pharma where when the company pled guilty for a second time in 2020, there were no individual executives even named. So as I say in the book, it's like it's a driverless car. 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, but I think it's sort of expressive of or 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 we saw in INS. And the Insys case is kind of particularly extreme. Insys is like everything you see in the Purdue story, but just like dialed up to 11. I think there were a bunch of reasons why you saw jail time in the Insys case and you don't in the Purdue context or in J&J. Was Kumar, wasn't that his last name? Yeah, I'm blanking on his name, but yes. Insys was just such a scam. And there you have like strippers working as sales reps and fairly sort of bald bribery schemes, not the soft corruption I've been talking about, but like the hardest of

hard corruption. So there you saw jail time. In my view, jail time is the only thing that really, that really is a deterrent. I think otherwise, I don't know. I mean, people are rational, particularly when it comes about money. They think about risk. They evaluate risk. You know, you look at the Sacklers, right? It's like you take $10 billion out of a company during a period of time when it's committing crimes.

You're going to have to give back $4.5 billion. Do you do it? You look at that fact pattern. You've got a company. The company commits crimes. You own the company. You're on the board of the company. You're never going to go to jail. You're never going to get charged with any crimes. You will have to give back $4.5 billion, but you can do it over nine years. Do you do it? I could probably go out on the street and find you some people who would say, hell yeah, sign me up. For the Sacklers, I think the real costs are going to be reputational and it's hard to measure that. You'd have to argue that,

are they any different from OJ Simpson? You mean in terms of the notion that everybody knows? Yeah. OJ Simpson commits this completely heinous, graphic, premeditated, violent act in front of the world. And if not for a technicality, effectively, and a racist cop gets off. But I don't think the world's ever really forgiven him. My guess is he probably is being basically socially punished for the rest of his life. And rightfully so. Is justice served? No, presumably not. He should be in jail, but nevertheless. So the blood of two people is on OJ Simpson's hands. The blood of how many people is on the Sackler's hands? Conservatively, what would be the most conservative estimate, right? I mean, it's so hard to say, right?

Do you look just at people who've OD'd on OxyContin? And of course they would say, again, with that parsing, they would say, ah, yes, but there were other drugs in their systems. Yeah. My point is of the half a million people who have died in the last two decades, I'm willing to acknowledge that some subset, maybe a small subset of those people, the blood is on the hands of this family. And work like yours has really brought that to light.

I just wonder what the rest of their lives 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? It's funny. I mean, I think both of the last two things you said are going to be the case. I think people will forever be embarrassed to be around them. I think the name is toxic and it's coming down off of institutions. I think it'll come down off of more institutions. I think that the family isn't happy about that. But I also don't

know that any of them feel any shame. One of the things that's been so revealing to me, it's funny, there's an analogy that I don't draw in the book in any explicit way, deliberately, but it was one that I thought about a lot is, you know, I was writing this book in the last years of the Trump presidency. One sense in which the Sackler situation, I think, was a little bit similar to Trump's. It's a sense in which I'm almost sympathetic in both cases, is if you're a billionaire, you're surrounded by advisors and lawyers and PR people and all these people whose livelihood depends on keeping you happy. I feel as though there is a kind of heightened danger of delusion, of you just getting out of touch with reality. And it probably starts in small ways. You tell a joke and everybody in the room laughs.

So initially, you're just like kind of a millimeter or two off track in terms of the fidelity of your perceptions of the world. The longer you go, the further off course you get. of your perceptions of the world, the longer you go, the further off course you get. And what you saw with Trump, which you also see with the Sacklers, is that there are people in the mix. I mean, I've 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. People who were making, frankly, 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. And the people who end up in the kind of 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. And what's been astonishing to me is they tend to pretty uniformly feel that way, the family members. Yeah, that's one of the things that surprised me about your book is you had to do all of this without actually talking to anyone in that family. And when you think 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, I don't think that happened, did it? Listen, my assumption from the beginning had been that there must be some apostate, third generation Sackler who looks around and never mind my writing, right? It's like they read the New York Times, they read the LA Times, they read Sam Quinones' book, Dreamland, and they say- Yeah, this is blood money. My trust fund is blood money. I don't need this. I'm going to turn my back on it. Couldn't find one. One of the more revealing documents, it's a WhatsApp log. It's like 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, and they're talking about their problems and how do you deal with it and the litigation and the bad PR and what's the right strategy. And it's this private channel. And there's nobody, nobody who at any point says, geez, maybe our critics have a point or like, maybe we should ask some tough questions. Instead, it's this pretty lockstep feeling of persecution. And in fact, I mean, sometimes when you read their private correspondence, the way they talk amongst themselves, at times it feels as though in their minds, like the real victims of the opioid crisis are the Sackler family. That's amazing. That's

more amazing to me than the indignant response that is seen publicly. It's that even privately, there's no awareness, not a shred of introspection. None. And a profound sense of grievance, a sense that they've been kind of persecuted. I mean, there's this amazing email that I quote in the book where Jacqueline Sackler, married to Mortimer Jr., a second generation member who was on the board of the company. She's talking about how with all this press coverage and the sort of stigma for the company. She's talking about how with all this press coverage and the sort of 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, children's lives are being destroyed. Not to pivot from the comic to the tragic, but like, I get emails every week from people who've lost children. When you hear from as many bereaved parents as I do, it's just amazing to read an email like that and consider the level of disconnection that it betrays. I know you've spoken about how you also hear from basically two groups of people, right? So you hear a lot from exactly what you've just said, the family members or friends of people who themselves have become addicted or who more tragically have lost those. But you also seem to hear from people saying your work is potentially threatening to the supply of pain medication to people like me who genuinely and legitimately need it, which of course is

not your intention. But you seem to be sensitive to that and you seem to understand that there's a fine line here, an overreaction or an overcorrection that would limit the supply of or access of patients who do need pain medication to it would be an unintended consequence of this work. So do you get a sense that that is actually happening? Yes. I mean, I think that there is a definite sense in which the pendulum has swung back and in which a lot of doctors are less likely to prescribe these drugs in the first place, more likely to prescribe shorter courses at lower doses. I think a lot of that is a good thing. Ultimately, there are many chronic pain patients. I certainly get emails from people talking about how they're fearful that their supply of these drugs, I'm not just talking about OxyContin here, but prescription opioid painkillers broadly,

that they 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. And it's an incredibly difficult thing. I mean, I am very sympathetic to this. I certainly don't want to see people who use these drugs stigmatized, whether they use them legally or illegally. I tend to be pretty sympathetic with people. I'm also not a prohibitionist.

You know, I don't, given all my work on illegal drugs, I tend not to think that drug prohibition is the way to go. People certainly make arguments that if you cut off pain patients, do rapid force taper and what have you, that that might actually drive people onto the black market and become more unsafe, that that might be part of what's driving the opioid crisis. Where I balk at that kind of, and this sort of goes back to the thing I said to you at the outset is the suggestion that I shouldn't write about the Sacklers and their culpability because there might be some second or third order consequence of that or that my focus is in the wrong place I'm going to write the books that I want to write in the articles that I want to write I find it's very often the case that people who are sort of telling me that I shouldn't be doing these things generally speaking haven't read the book I haven't's very often the case that people who are sort of telling me that I shouldn't be doing these things, generally speaking, haven't read the book, haven't really engaged

with the particulars all that much. But yeah, look, I do hear from pain patients quite often. And I think this has been a sort of an agonizing period for them because from where I sit, the problem was not that a drug like OxyContin shouldn't have been produced or made available to pain patients. It was all in the decision to do two things. One was dramatically expand the universe of people who should be taking it. And the other was, I think, pretty systematically play down the risks so that

there's a dishonesty with the consumer and with physicians about what the dangers are. I don't go from that to any sense that these drugs should not be available at all. There are some who do, some doctors who do. I sort of don't feel the need to go there myself. I'm 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. 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. So as you point out,

we still have an opioid crisis. And in fact, it doesn't seem to be showing any signs of abatement. In fact, last year, we saw more people die of opioid overdose than any other cause of accidental death, which is actually a staggering statistic when you consider how many people die in car accidents, how many people die of gunshot wounds. In that sense, your work has been a success and the work of all the people you've written about who have finally brought a modicum of justice to at least the initial perpetrators of this. But what does the path forward look like? What will it take to actually address this crisis? This will sound like a cop-out, but in some ways, I'm so overwhelmed by that question. I think anybody would be. The way in which I've grappled with that is to kind of take this small piece of it that I can focus on and understand. And for me, in some ways, it's kind

of looking at the origin story of the crisis really more than where we are now. The numbers are staggering. As you say, they're getting worse. The sense in which I feel as though the Sacklers are not absolved by the fact that this is today a heroin and fentanyl crisis is the sense in which there are many, many people who I think would never have taken heroin or fentanyl in the first instance that started on prescription opioids like OxyContin. But of course, from the vantage point of today, I'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. I feel as though we need far more resources than we have. I mean, I think it's a problem that needs to be resourced.

I think treatment is very often not available to people. I think there's still a huge amount of stigma associated with the abuse of an addiction when it comes to these types of drugs and anything we can do to diminish that stigma. I think medically assisted treatment, which I think there are still some for whom that's a kind of a scary concept. It's one that should be adopted and embraced and not cause the consternation that it does for some. But I think it's a huge national crisis. And in a strange way, I feel as though were it not for COVID, it's not that the problem would have been solved. Just prior to COVID,

there was a sense in which I, you know, it's tricky because it was the Trump administration. But I think there was sort of a recognition that we need a major national strategy to deal with this. It is out of control and killing people in vast numbers. And we need to have all ideas on the table and be strategic and resource the solution. And then COVID came along and there just wasn't really the bandwidth or the oxygen in the room to have that conversation. But when we neglect the problem, as we have during COVID, purely in terms of the triage or the last 18 months, you see what happens. Are you optimistic that 10 years from now, things will be different? I mean, I have to be just because I'm, believe it or not, after this grim conversation, I'm fundamentally an optimist about a lot of things. I have to believe we will learn and we'll sort of find a way out of this.

But it's hard. And I think the hardest thing in a way is I've had many of these conversations and sound like you have too. You mentioned a patient who had a family member 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 you talk to people who've sort of achieved, they've found their way out of the woods. Often the thing that's so striking to me is that there's a sort of fragility to it. They're always talking in the present tense. There's this sense that kind of every day

is a battle. And that's what worries me about the idea of us 10 years from now on a kind of every day is a battle. And that's what worries me about the idea of us 10 years from now on a kind of very micro level for the individual who is struggling with addiction. There's that sense in which it's like each tentative step, you just never know when you're going to get pulled back in. And so on a kind of macro level nationally, I worry that there may be a similar danger. Yeah. I worry about the impact of what it takes to escape the gravitational pull of an environment that facilitated the use. I did my residency at Hopkins, which is in inner city Baltimore. And even 20 years ago was probably a leading indicator for how bad heroin use could get. We 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. So 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. And so you would take care of these patients and you always wish them the best when they left. But in the back of your mind, you knew you were going to see them again because even though for the five days that they were in the hospital, they were not using any drug and they, with the total clarity of the thought that they had, 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. And we used to say to ourselves, 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 that might sound like a very extreme example, right? Well, come on, inner city Baltimore. I mean, you're talking about a crack house, but is it really any different for a college kid who's trying to desperately get off the transition from oxycodone to fentanyl. And 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. I mean, it's really difficult. That's the part that concerns me is it's hard to do this one person at a time. Yeah. I come back to the, you know, that idea of undertow and even you telling your own story about your experience with OxyContin. I think the big thing that comes home to me is just that these substances are, they have an awesome power

and that's compounded by all of the kind of atmospheric, social, situational things you're talking about. But just having talked to a lot of families over the years who've dealt with this and they thought they were out of the woods and then they weren't, I think you're talking about. But just having talked to a lot of families over the years who've dealt with this and they thought they were out of the woods and then they weren't, I think you're right. In any one individual life, and even somebody who actually has a really supportive, got a whole support system there. And in many instances, there are people who they don't have the resources for the appropriate treatment. But in many instances, there are people

who do, who throw resources at the problem. And it's not enough. It's not adequate. I just think we should all be sort of humble and mindful in the face of the tremendous kind of potency and power that's on the other side of this problem. Patrick, thank you very much, first and foremost, for your book and your investigation, which I think has brought to light a lot of things that probably could have easily gotten ignored or swept away. I mean, 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 you've done a better job of that with respect to

this important part of the story than anybody else. But also thank you for making time. I imagine as an author, you must get tired of having to do interviews on the same topic, but I really appreciate it. Thank you, Patrick. Really in depth. And yeah, I very much enjoyed it. It was a great conversation. Thank you. Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you more in-depth exclusive content without relying on paid ads. It's our goal to ensure members get back much more than the price of the subscription. Now to that end, membership benefits include a bunch of things.

One, totally kick-ass comprehensive podcast show notes that detail every topic, paper, person, thing we discuss on each episode. The word on the street is nobody's show notes rival these. Monthly AMA episodes or Ask Me Anything episodes, hearing these episodes completely. Access to our private podcast feed that allows you to hear everything without having to listen to spiels like this. The Qualies, which are a super short podcast that we release every Tuesday through Friday, highlighting the best questions, topics, and tactics discussed on previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and necessarily listen to everyone.

Steep discounts on products that I believe in, but for which I'm not getting paid to endorse, and a whole bunch of other benefits that we continue to trickle in as time goes on. If you want to learn more and access these member-only benefits, you can head over to peteratiamd.com forward slash subscribe. You can find me on Twitter, Instagram, and Facebook, all with the ID peteratiamd. You can also leave us a review on Apple Podcasts or whatever podcast player you listen on. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice.

No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peterottmd.com forward slash about where I keep an up-to-date and active list of such companies. Thank you.