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

00:00:00.000 Hey, everyone. Welcome to the drive podcast. I'm your host, Peter Atiyah. This podcast,

00:00:15.480 my website, and my weekly newsletter all focus on the goal of translating the science of longevity

00:00:19.800 into something accessible for everyone. Our goal is to provide the best content in health

00:00:24.600 and wellness, full stop. And we've assembled a great team of analysts to make this happen.

00:00:28.880 If you enjoy this podcast, we've created a membership program that brings you far more

00:00:33.280 in-depth content. If you want to take your knowledge of this space to the next level,

00:00:36.820 at the end of this episode, I'll explain what those benefits are. Or if you want to learn more

00:00:41.320 now, head over to peteratiyahmd.com forward slash subscribe. Now, without further delay,

00:00:47.740 here's today's episode. My guest this week is Patrick Radden Keefe. Patrick is an award-winning

00:00:55.020 staff writer at the New Yorker magazine and a New York Times bestselling author. His most recent

00:00:59.300 book is about the opioid epidemic. It's a New York Times bestseller. The title of that book is

00:01:03.900 Empire of Pain, The Secret History of the Sackler Dynasty. I've been wanting to do a podcast on the

00:01:10.640 opioid epidemic for some time, and I've been trying to think of the right way to do it.

00:01:15.700 Recently, I saw the HBO documentary, The Crime of the Century, and I thought it was a really good

00:01:23.020 and thorough overview of the problem. Now, this is a problem that has many layers to it, right? It has

00:01:29.800 the organizations that actually make these drugs, so the producers of the pharma companies. It has

00:01:35.620 the organizations that distribute these drugs between the producers and the end-stage or end-use

00:01:42.360 retailers, so the intermediaries. It has then, of course, the retail side of things where these drugs

00:01:48.040 are purchased, the physicians who prescribe these drugs, the patients who use these drugs,

00:01:54.120 the enforcement agencies that regulate them, the FDA that approves these drugs, and even the medical

00:02:01.700 advocacy groups that provide guidance to physicians about them. When you consider the landscape of this

00:02:09.000 problem and all of the actors that I just went through, you come to realize that every one of them

00:02:15.620 plays some role in the situation we're in now, the situation where basically half a million people

00:02:21.840 have died in the past 25 years from opioid overdose, and where opioid overdose now represents the leading

00:02:29.040 cause of accidental death in the United States, ahead of car accidents, gunshots, things like that.

00:02:35.520 What Patrick's book does is go straight to the heart of the matter. How did this begin? What was the

00:02:41.640 thin end of the wedge that created this epidemic? He makes a very compelling case that it was the

00:02:48.340 company Purdue Pharma, a privately held company run by the Sackler family. In this episode, we talk at

00:02:55.040 great length about the history of the Purdue Pharma company and its management team. We talk about

00:03:02.680 the implicit and sometimes explicit corruption that existed. We talk about the other

00:03:11.460 players in this channel, the physicians, the regulators, the politicians, again, none of whom

00:03:20.020 really get off scot-free in this assessment. This is a bit of a depressing episode. I'm not going to

00:03:26.360 lie to you. I don't think we come away from this with an enormous sense of optimism that this solution

00:03:30.760 is in hand and that five years from now, we'll look back at this and marvel at how easily it was able

00:03:36.640 to be solved. I personally don't have a great sense of how that's going to happen. But nevertheless,

00:03:41.480 I feel it is important to at least expose and shed some light on how we got here. So without further

00:03:46.360 delay, I hope you'll enjoy my conversation with Patrick Radden-Keefe.

00:03:54.920 Hey Patrick, thank you so much for making time to sit down. I know you've done a number of these

00:03:58.800 interviews and one of the things I always like to do is try to go places or at least deeper than maybe

00:04:03.200 you've gone before. So we'll see if that can be accomplished. There's certainly no shortage of

00:04:06.820 material here to dive into. But I guess I kind of want to start with a question that I know you've

00:04:12.240 probably spoken about before, which is what drew you to this story? Because the depths that you've

00:04:17.200 gone to to research your book have been certainly at the upper decile, I would suppose, of what an

00:04:22.540 investigative journalist would do. It's great to be with you and happy to talk about how I came to

00:04:26.880 this. I've always been interested in drugs as a subject. The way in which drugs fit into

00:04:32.980 our society, how we feel about them, which drugs are illicit, which drugs are illicit.

00:04:38.820 I wrote a big piece a number of years ago about the legalization of cannabis in Washington state.

00:04:43.200 Very interested in this idea that you have this existing industry, this pot industry that's been

00:04:47.900 around for decades with the stroke of a pen at midnight. It's legalized. And what does that look

00:04:53.380 like? How do you turn it into a taxed and regulated economy? And I had done a lot of writing on Mexican

00:04:59.360 drug cartels. So I did a big piece, actually, before I was full-time at The New Yorker. I did

00:05:04.140 a cover story from The New York Times Magazine back in 2012 about the Sinaloa drug cartel. And to give

00:05:10.140 you a sense of context, I mean, at the time, I had to explain to the editors of The New York Times

00:05:14.460 Magazine who Chapo Guzman was. He was not a household name at all. And the idea there was I wanted to do

00:05:20.460 sort of a Harvard Business School case study of a cartel. I wanted to look at it as a multi-billion dollar

00:05:26.360 transnational commodities enterprise. I was really interested in how they diversified and

00:05:31.960 how vertically integrated they were. And one of the questions that grew out of that research was

00:05:38.120 you saw at a certain point a surge in heroin. So they had different problems. I mean, Sinaloa

00:05:43.980 dealt in cocaine, marijuana, heroin, and methamphetamine. But after 2010, you start seeing

00:05:52.040 more Mexican heroin, huge volumes of it coming across the border in ways that it hadn't been

00:05:57.480 before into the US. And that was kind of a riddle that I started with was this question of, you know,

00:06:04.220 why this sudden uptick in heroin? And the answer was the opioid crisis. And so it was one of these

00:06:10.480 funny things where I started out with an inquiry that was kind of solidly grounded in the realm of

00:06:15.720 the illicit drug trade and found my way into the world of the FDA-regulated legal drug trade

00:06:23.600 with OxyContin and Purdue Pharma and sort of started looking into the origins of the opioid crisis and

00:06:29.560 then discovered that this company, Purdue, was owned by the Sackler family. And that kind of blew my

00:06:34.620 mind, the idea that this family that's quite well known for philanthropy had made such a huge fortune on

00:06:40.980 this drug with such a controversial legacy. That was kind of the way in for me.

00:06:44.920 I kind of drew on a piece of paper a long time ago when I was trying to get my mind around this,

00:06:52.260 how many actors there were. The paper looked something like this, right? It started on the

00:06:56.380 left and it had producers. I was talking about this not through the illicit chains. So you had

00:07:01.540 sort of the pharma companies of which Purdue would be the champion of them. And then you have the

00:07:06.500 distributors or the intermediaries, the McKessons and the Cardinals of the world. I actually knew a lot

00:07:10.980 about McKesson through a previous life. So I was intimately familiar with what companies like

00:07:15.280 McKesson did and how they were able to distribute products from the producers to the retail, the

00:07:20.700 pharmacy, the CVSs of the world. So that became your third actor. Your fourth actor then became

00:07:25.880 the FDA in the approval process of a drug and then the DEA around enforcement. You could even put those

00:07:31.580 two in a bucket. You then have the regulators that create, or the policymakers rather, that create the

00:07:35.840 policies that allow these entities to exist. And then you have the providers, people that write the

00:07:41.300 prescriptions for these things. And ultimately you have the patients. So that's maybe a bit of an

00:07:45.340 oversimplification, but it gives you a sense of just how complicated this web is. Now we're going to spend

00:07:50.260 a lot of time talking about one entity within one of those buckets. So why do you think that that is

00:07:57.900 a place for someone who's maybe listening to this podcast to get a pretty good sense of the magnitude of

00:08:05.140 this problem? Because I don't think anybody could with a straight face say there isn't a problem.

00:08:10.360 You'll put some numbers to what that means. But it's interesting that perhaps the study of Purdue

00:08:15.280 Pharma and the Sacklers, more than any other single entity in that entire chain that I explained,

00:08:21.620 could provide a greater context of what we're up against. Would you agree with that? I mean,

00:08:25.740 I'm assuming you have a bias. Otherwise you wouldn't have studied them so extensively.

00:08:29.580 It's great that you lay it out with that much nuance, because that's the kind of nuance that often gets

00:08:33.800 lost. So there's two things I'd say. I mean, one is a kind of observation that I would make as a

00:08:39.980 writer and a journalist and somebody who writes books is I go where my interests lead me. I write

00:08:45.200 stories that I think are interesting stories, interesting to me that I think are important,

00:08:49.640 that I think would be interesting to readers. It's very, very often the case that I'll spend a lot

00:08:53.460 of time on something and the reaction that people have is, well, why did you pick this? Why didn't you

00:08:57.460 write about this other thing? There's this other variable that's very important here. And I

00:09:01.940 instinctively resist those types of questions because on some level, I feel as though it's

00:09:07.140 my prerogative as a writer to pick the area that interests me and do it and hopefully do it well

00:09:12.640 in a way that has some integrity. But I make no claim to suggesting like this is the be all and

00:09:18.220 end all. So in this case, if it's the opioid crisis, there would never be any suggestion that

00:09:22.040 this is the only book you need to read on the opioid crisis. And to segue from that into the

00:09:26.480 particulars here. So when we talk about the opioid crisis, we're talking about an incredibly

00:09:31.120 complex public health crisis that unfolds over the course of a quarter of a century. Today,

00:09:35.580 the numbers are a little imprecise, but you have at least a half a million people who've died

00:09:41.400 from opioid overdoses since the mid to late 1990s. By some estimates, you have two plus million

00:09:49.000 Americans today struggling with an opioid use disorder of one sort or another. And when we talk

00:09:54.960 about opioids, that's actually a kind of pretty capacious category, right? So it's regulated drugs like

00:10:00.540 OxyContin, but it's also fentanyl that comes in from China or Mexico. It's heroin. And in fact,

00:10:08.620 when you talk about the death toll today, I think the Sacklers certainly would be quick to say,

00:10:14.680 today people are dying in very large numbers from heroin and fentanyl overdoses, not from

00:10:20.000 OxyContin or indeed, you know, from most prescription painkillers. This problem has kind of transitioned

00:10:26.120 into an illicit drug problem. So why pick OxyContin and why pick the Sacklers? In my view,

00:10:32.920 you know, in part because it's an interesting story, I'm interested in the fact that this was a

00:10:35.920 family, family dynamics are interesting to me, in part because of the philanthropic legacy, because

00:10:42.420 there's this kind of disconnect or there was until recent years between the reputation that the family

00:10:47.700 had and what I would argue is the reality of their business. But most importantly, because I think

00:10:52.220 OxyContin was sort of the, in the words of somebody who worked on the drug, was the tip of the spear,

00:10:56.580 the kind of nuance that often gets lost. It can be possible to stipulate that today,

00:11:00.580 the opioid crisis is a heroin and fentanyl crisis. And also to keep in your mind, the idea that

00:11:06.760 absent OxyContin, we might not be where we are today, that it was the kind of first mover

00:11:13.040 in terms of changing prescribing habits in the United States in a way that had really fundamental

00:11:19.740 consequences and ultimately built up a market for these drugs, a market which eventually migrated

00:11:26.400 to illicit sources of supply. That would be the reason, I'm sure we can talk about it in more

00:11:32.300 detail, but I think there's kind of a special role that Purdue and the Sacklers played, which is not

00:11:37.140 for a second to suggest that there isn't blame with all those different buckets that you mentioned,

00:11:41.440 because there absolutely is. Based on what I've read of your writing, you also seem very well

00:11:46.220 informed about those other buckets. So I definitely want to make sure we touch on them, but there's

00:11:50.220 no place to start like where we're going to start. So let's start with the three Sackler brothers.

00:11:55.340 Take your pick of who you want to begin with, Arthur, Raymond, Mortimer. Who were these guys? What

00:12:00.280 got them interested in pharmaceuticals? I mean, you have to start with Arthur. I think you've got

00:12:04.820 these three brothers. They were the children of immigrants. Their parents had come over from Europe

00:12:08.860 at the turn of the last century, settled in Brooklyn. They were Jewish. The parents didn't speak

00:12:14.280 English really all that well. Initially, they spoke Yiddish in the home. They raised their kids to

00:12:20.820 believe in a few things. I think to believe in education, to believe in meritocracy. There are

00:12:27.140 these kind of very American, like mythical contours to the early parts of this story, where there's a

00:12:33.120 family that came with nothing and had an expectation that within the span of one generation, they would

00:12:39.580 build an empire and really kind of make their mark on the country and the world. And they were right.

00:12:45.000 So they raised these three brothers. Arthur later said that from the age of four, he knew he would be

00:12:49.880 a doctor with a sense that you're all going to grow up, you're going to get educated, you're going to

00:12:53.640 become physicians. And there was a sense that there was kind of nothing as prestigious and virtuous

00:13:00.480 as being a doctor. I think there was a real veneration in this family for the role of the

00:13:07.040 physician in society. And so the brothers grow up, but they also grow up against the backdrop of the

00:13:12.780 Great Depression. There's a period where their father loses everything. And so there was an

00:13:17.900 expectation that you also have to go out there and hustle and make money and have jobs. And so all

00:13:22.540 three brothers work multiple jobs. I'd say in the book of Arthur Sackler, it's like he squeezed

00:13:28.060 four or five lifetimes into one lifetime in terms of everything that he did. They end up eventually

00:13:34.480 in the pharmaceutical business, but the way they get there is through pharmaceutical advertising and

00:13:39.840 marketing. And that actually starts back in high school. When Arthur Sackler's in high school, he

00:13:44.100 gets jobs on the student publications. He's at this huge high school, Erasmus Hall High School. It's

00:13:48.640 something like six or 7,000 students in Brooklyn, in Flatbush. It's still there today. He gets jobs,

00:13:54.560 you know, on the student magazine, the student newspaper, but he becomes the advertising manager.

00:13:59.200 And if you think about it, you have six or 7,000 students that you can reach. That was a real job.

00:14:04.020 And so that's where the hustle starts with Arthur. And all three brothers end up training as

00:14:09.880 psychiatrists, practicing as psychiatrists, but they pretty quickly pivot into commerce.

00:14:17.640 So what were the types of drugs of that era that were really making a difference in their

00:14:23.700 practice? It seems that sedatives were potentially becoming of interest in that era.

00:14:30.340 You have this kind of early, amazing moment. There's this pattern that asserts itself with

00:14:34.560 the brothers where Arthur goes and he does something, and then he kind of brings his brothers

00:14:37.840 in with him. That starts in high school, got more jobs than he can handle. So he starts handing them

00:14:43.220 off to the brothers. And he ends up at the Creedmoor Psychiatric Hospital, which is a huge asylum,

00:14:49.300 vast kind of industrial asylum in Queens, New York, public state mental hospital.

00:14:55.740 With a staggering capacity, right? It's something like 6,000 beds. When I read that,

00:14:59.580 I thought that can't be possible. I don't know what that would look like. I literally can't picture

00:15:04.120 the infrastructure large enough to have 6,000 inpatient beds.

00:15:08.180 Yeah. I mean, it was a vast facility. I believe it was a facility designed for 4,000 beds. You know,

00:15:13.880 it's interesting because in these years, this is pre-thorazine. It's like the last maximalist phase

00:15:21.060 of big state mental hospitals, people basically being warehoused for life in these facilities.

00:15:27.440 It's just prior to the deinstitutionalization that happens in the decades that follow. And so

00:15:32.660 the brothers get there and they're shocked by the conditions. And also, if you think about it,

00:15:37.240 I mean, Arthur in particular, he was a Freudian. He trained us a Freudian, right? So like,

00:15:40.540 not a lot of talk therapy happening at a 6,000 bed hospital.

00:15:44.480 Were they still doing lobotomies and things like that?

00:15:46.660 They were. I mean, in fact, lobotomies start up during this time. It's a lot of electroshock

00:15:50.960 treatment and then lobotomies. And I should say, I mean, electroshock has its defenders. Even today,

00:15:56.680 it is very successful for some people in some circumstances, but the Sackler brothers are there

00:16:01.800 and they're administering it thousands of times. And I think it just became more and more demoralizing

00:16:07.360 for them because they just felt as though, how can we as physicians not have developed some

00:16:13.300 more humane way of administering to our patients? They develop, even at that point, this theory that

00:16:22.240 a lot of the afflictions they're seeing probably have some basis that is fundamentally chemical.

00:16:28.040 And if that's the case, then there's probably some chemical solution. The brothers don't have

00:16:32.180 anything to do with Thorazine, but when it comes along, they see that. And this is in some ways,

00:16:36.620 a kind of glimpse of the future that they had envisioned. And it was, I think, generally

00:16:41.400 speaking, an exciting time in the pharma business. You have penicillin, it's a huge game changer in the

00:16:46.420 Second World War. And then a lot of these companies that today we think of as like big pharma, prior to

00:16:52.480 the Second World War, they didn't really look like they do now. They were producing chemicals, but they

00:16:58.040 weren't really producing branded drugs in quite the same way. And then you just get this go-go period

00:17:03.840 where they're all competing and they're developing new antibiotics and they're coming out with new

00:17:10.380 products every few weeks. And suddenly they need to differentiate themselves. And consumers are,

00:17:16.660 they're no longer going to the pharmacy and having the pharmacist mix whatever it is that their doctor

00:17:21.860 has prescribed. They're going in and requesting drugs by their brand name. It's in that exciting,

00:17:28.540 I think, quite idealistic whirlwind climate that the Sacklett brothers come of age.

00:17:35.760 Where did Purdue Pharma come from? Was it a company that they founded? Was it something that

00:17:40.320 they bought and later transformed?

00:17:42.360 It was the latter. Its origins date back to the 19th century. It was a little patent medicine company

00:17:47.900 based, funnily enough, on Christopher Street in Greenwich Village, which is like, you can go to the

00:17:52.720 building that it once occupied. It's just funny that what had once been the humble Purdue

00:17:56.620 Frederick factory is like today, somebody's $18 million townhouse. In 1952, Arthur Sackler had

00:18:05.300 already achieved a great deal of financial success, not in the drug business per se, but in

00:18:11.240 pharmaceutical advertising. He really makes his name by joining and then taking over a pharmaceutical

00:18:19.280 advertising firm. And he's a genius for advertising drugs. At this point where all these drug companies

00:18:24.900 need to figure out ways to differentiate their products and reach doctors and persuade them to

00:18:28.980 prescribe. With some of the money he's made, Arthur purchases this company, Purdue Frederick,

00:18:34.380 and he basically gives it to his brothers. So he remains, he's a stakeholder in the company. He owns a

00:18:39.800 third of it, but he's a silent partner basically. And the brothers will run the company starting in 52.

00:18:45.420 And what happens over the next 30 years?

00:18:47.340 Purdue Frederick is a very successful company. I mean, the brothers get rich, but they're getting

00:18:54.140 rich in a way that is, I think that even Arthur would probably have sniffed at. Because Arthur,

00:19:01.320 who again, is one of the owners of the company, he's really focusing on the marketing of pharmaceuticals.

00:19:07.560 His big success is, I mean, he had many successes, but his biggest success is that he designs the marketing

00:19:13.760 and advertising strategy for the minor tranquilizer Librium, and then for Valium, both of which Roche

00:19:19.980 develops. And Librium becomes the biggest selling drug in the history of the pharmaceutical industry.

00:19:26.200 And then it's surpassed only by Valium. And then for years, the two of them are in the top five drugs

00:19:30.840 nationwide. And Arthur designed all the advertising and the marketing for that. And he devised this

00:19:37.480 interesting compensation scheme where basically he said, I'm going to get an escalating series of bonuses,

00:19:42.420 depending on how many pills you sell, and there's no ceiling. So he becomes vastly wealthy on the basis of

00:19:49.560 these drugs. His brothers, meanwhile, what they're doing is less cutting edge. They basically license

00:19:55.040 over-the-counter products and then sell them. And they were really smart about it. So they had a

00:20:01.840 antiseptic solution, Betadine, which is still out there. And they got the rights to that just before the

00:20:07.020 Vietnam War. It had kind of battlefield applications in Vietnam. They had a laxative, Seneca, very

00:20:14.320 successful. These are these kind of cash crop products. They're very unglamorous, but they're

00:20:19.300 staples, over-the-counter stuff, but year in, year out, very, very successful.

00:20:23.900 The irony, by the way, of the company that would create the opioid boom having a laxative, which

00:20:29.660 is, of course, there to address one of the most painful short-term consequences of opioid use being

00:20:35.900 constipation. Well, and the crazy thing is that they, eventually, it gets to a point where the sales reps

00:20:41.700 for Purdue would go out and they'd market the one with the other. They would market them together. But it's

00:20:47.660 really only in the 80s that the company starts getting more, late 70s, early 80s, the company starts

00:20:53.120 getting aggressive about really investing in R&D, developing its own prescription drugs. And it's at that

00:21:00.580 point that they move into pain management. Any inclination from your research why they decided to keep

00:21:05.800 this company private, as opposed to take it public, like many of the large pharma companies?

00:21:11.600 I can only speculate, but the Sacklers had a real sense, I think for a long time, that this was a

00:21:19.220 old world enterprise, that it was a family business. It was family owned, physician owned,

00:21:25.340 they would always say. There was a sense that they controlled it. And they thought of the people

00:21:31.500 who worked for them as family. It's really only with the advent of OxyContin in the 90s that becomes

00:21:37.760 this multi-billion dollar company up to that point. It was a pretty modest outfit. The Sackler brothers

00:21:44.380 themselves did really well. They were very wealthy, but it was a kind of manageable family firm. And I

00:21:51.920 think that there was something to that. I don't know what it would have looked like if it went public.

00:21:55.500 I do know that you've kind of put your finger on something there because I think when you get into

00:22:01.400 the later stages, post the introduction of OxyContin, there's a lot of stuff that happens

00:22:06.340 in this story that would never happen in a public company. That's the revisionist history in me,

00:22:11.880 which is saying like, had they been a public company, how far would this have gone?

00:22:16.280 Yeah. I mean, I don't mean to suggest that. I think in the early going, we can sort of get into

00:22:20.260 the particulars, but there are these like hinge moments in this story. We've got all the stuff that

00:22:24.400 happens prior to the introduction of OxyContin. And then you start seeing things go wrong and then

00:22:29.800 they go more wrong. And it's like, well, how do you handle it when you see, how do you handle it

00:22:34.120 when you start getting calls saying that the product that you sell is killing people? And I think that

00:22:38.080 probably would have been a different response in a public company. And then the really crazy thing is

00:22:42.700 eventually we're getting ahead of ourselves here, but eventually you get a guilty plea in a federal

00:22:47.100 criminal case in 2007. I think at a public company, if you had that, I just think heads would have

00:22:53.720 rolled. You'd have a total change of personnel, big shakeup on the board. At a privately held family

00:23:00.540 company, what happened was like... Pretty much nothing. Yeah. Yeah. Yeah.

00:23:05.180 So talk a little bit about MSContin as the precursor to OxyContin and maybe the pharmacokinetics of it,

00:23:11.980 but more importantly, what that transition was about. In the 1980s, you saw, actually dating back to the

00:23:19.480 70s, a kind of revisionist school of physicians who felt in the UK and in the US and other parts

00:23:25.660 of the world who felt that the medical establishment had been not taking pain seriously enough as a

00:23:31.880 problem. That doctors weren't treating pain aggressively. They were treating it just merely

00:23:36.820 as a symptom, not as a problem in and of itself. That there wasn't enough medical education for

00:23:42.720 physicians in terms of identifying pain and responding to it. And going along with this was

00:23:48.600 a sense that many physicians had that there was a resistance to prescribing opioids out of a fear of

00:23:55.840 addiction, that doctors had been too stingy in prescribing opioids for pain because of concerns

00:24:01.760 about abuse and addiction. And it's in this context that MSContin, this drug, has developed. And it's a

00:24:07.360 cancer drug. It's a drug for cancer pain. And it's basically just morphine. But the real innovation

00:24:13.000 was the Conten part. So Conten, short for continuous, it's essentially the coating on the pill.

00:24:19.420 And the idea is that this will regulate the flow of the drug into the bloodstream over the course of

00:24:25.020 hours. MSContin was developed in the UK and then rolled out in the US. It was a groundbreaking drug in

00:24:31.580 its way. Very successful for the company. I don't remember exactly what it was generating in terms of

00:24:36.580 revenue at its height, but $300 million or $400 million a year, which was a lot for Purdue at the

00:24:42.620 time. It was a big success. And I think that the family was proud of it. There was a sense that they

00:24:49.140 were doing a good thing, relieving terrible pain for people suffering from cancer and doing very well

00:24:55.660 financially. And so they were in this world of doctors who were thinking about pain and wanting to

00:25:00.880 kind of re-evaluate the way in which pain is treated, they were heroes. And you had this

00:25:06.340 interesting, and I don't think necessarily altogether cynical, confluence of interests in

00:25:12.460 which Purdue starts sponsoring academic conferences on the treatment of pain and medical conferences

00:25:18.120 and seminars. And they're sort of out there with an obvious commercial interest, but also I think a

00:25:25.580 sense that we're part of a revolution here. We're going to revolutionize the way in which pain is

00:25:29.240 treated. Whose idea is OxyContin? I mean, in some sense, it's an obvious leap because if MSContin is

00:25:36.460 simply morphine sulfate formulated in a continuous fashion, there are other narcotics out there.

00:25:42.960 Percocet already existed. It was simply hydrocodone with acetaminophen. Hydrocodone existed by itself

00:25:50.760 in a non-time released format. So was there great innovation basically saying, we're just going to make

00:25:56.980 a time release version of hydrocodone just as it had been done with morphine? Was that effectively

00:26:03.280 the aha moment?

00:26:04.200 Something I mean, I should say, and this will be not a surprise to you, but to me coming from the

00:26:09.200 outside, I was really startled. I knew as a kind of objective analytical matter that the life cycle of

00:26:16.020 a patent is very important to a drug company. I don't think I fully appreciated the degree to which

00:26:21.080 it is the sun and the stars and it's everything. There were so many points in the course of my

00:26:27.080 reporting for this story where there'd be some sort of mystery about motivation. There'd be some weird

00:26:31.460 thing that they did and I couldn't figure out why. And I would puzzle over it and puzzle over it and

00:26:36.000 puzzle over it. And then it always turned out to be something having to do with a patent.

00:26:39.340 For example, the pediatric indication?

00:26:41.560 The pediatric indication. Very good example. At a point where OxyContin was hugely controversial

00:26:46.180 already and causing all kinds of problems, they applied for the pediatric indication for the drug.

00:26:51.120 And I couldn't figure out why. And they had all these explanations that turned out to not be true.

00:26:55.740 And then it turned out it was because they thought they would get an additional six months of

00:26:59.580 patent exclusivity if they got it. In the case of MSContin, the patent is running out at a certain

00:27:06.620 point and they realized that it's going to decimate their profits. And so they just start talking about,

00:27:12.340 hey, what else could we put with the content system? And the family dynamics here are a little

00:27:18.340 humorous, but there's, according to Kathy Sackler, who's one of the second generation Sacklers who's

00:27:22.900 involved in the company and is a medical doctor, she has dinner with Richard Sackler, her cousin,

00:27:27.400 and kind of rival within the company at a certain point. And she suggests, what about OxyCodone?

00:27:33.760 And according to her, Richard didn't know what OxyCodone was. And she had to explain.

00:27:38.620 And OxyCodone is stronger than both Hydrocodone and Morphine.

00:27:43.100 It is. Part of what's interesting about OxyCodone is that there's this amazing thing that happens

00:27:47.440 basically where they make their decision, okay, we're going to use OxyCodone. We'll develop OxyContin.

00:27:51.640 There are these conversations that happen, and they happen over email. And I have the emails

00:27:56.700 where these senior executives at the company and Richard Sackler are talking about the market and

00:28:04.780 the idea that MS-Codone was a drug for cancer pain and the stigma associated with morphine.

00:28:11.940 This notion that if you're a regular person, not a doctor, and your doctor tells you that your

00:28:16.420 mother's going on morphine, that means your mother is going to die. And what they realized

00:28:20.880 is that OxyCodone didn't have those same associations, even though it's stronger than

00:28:25.980 morphine. They did focus groups. And you have OxyCodone in Percocet and in Percodan.

00:28:31.520 And that was the primary way in which physicians were encountering those drugs.

00:28:35.700 I misspoke earlier. I said it was Hydrocodone. It's actually OxyCodone. That's right. Yeah.

00:28:39.640 And when they're cut with aspirin or acetaminophen, it's a relatively small dose. There's only

00:28:44.440 so much you can take. What they noticed in these focus groups is that physicians had a sort of a

00:28:49.620 sense of OxyCodone as more benign, less threatening. There was less stigma, but also they saw it as

00:28:55.280 weaker. There are these incredible emails where they say, well, listen, there's only so many people

00:28:59.320 who have cancer pain. We did great with our cancer drug, but there's a much bigger market out there

00:29:04.660 of people suffering not just from severe pain, but moderate pain, chronic pain, back pain, sports

00:29:10.880 injuries. There's a funny cartoon you could envision here, which is another revisionist,

00:29:15.400 which is imagine if instead they just decided to figure out a way to make more cancer patients.

00:29:19.920 How could we do to increase the number of people dying of cancer to expand our market? And then

00:29:25.780 someone goes, no, no, no, no, that's too hard. That's too hard. I got a better idea. Let's just

00:29:30.040 figure out a way to make everybody who doesn't have cancer takes this drug.

00:29:33.860 Right. And in fact, to sort of create the need, which is a big part of what the marketing ended up

00:29:38.040 being. Yeah. I mean, the analogy that I come back to, the first third of the book is devoted to

00:29:43.180 Arthur Sackler and those earlier years. And that was a very deliberate choice, even though Arthur

00:29:47.640 Sackler dies in 87 before the introduction of OxyContin, because I think there are all of these

00:29:52.060 things that happen earlier that are kind of the seeds for what comes later. So the analogy I always

00:29:57.000 think of is Thorazine, which the original Sackler brothers see. Thorazine is a major tranquilizer

00:30:02.220 for people who are psychotic, very successful, emptied out the asylums pretty quickly. I mean,

00:30:08.680 there were other things that did as well, but it was a real game changer. But there's only so many

00:30:12.340 people who are actually require that kind of heavy duty solution. And then Arthur Sackler makes his

00:30:17.080 fortune on the minor tranquilizers, where who among us doesn't feel a little stressed at the end of the

00:30:22.020 day? Who couldn't benefit from something to make them relax a little bit? And that was what turned

00:30:28.780 Librium and Valium into these huge blockbusters. It's kind of a similar thing here, where there's

00:30:33.560 this sense that, you know, MSContin is a drug for this subset of people who are experiencing terrible

00:30:38.560 cancer pain. There's a much bigger community of people who have moderate pain. But the weirdness of

00:30:45.500 it is that they then take a drug that is stronger, not weaker, and market it that way. And you see these

00:30:50.940 emails in which these executives say, in our focus groups, doctors erroneously think that oxycodone is

00:30:58.500 weaker than morphine. Let's not do anything to make them realize that they're wrong about the product

00:31:05.380 that we're selling them. Because if we did, it could constrain our market.

00:31:10.420 So they developed this new drug. What's unusual about the process by which it receives its FDA

00:31:17.200 approval? A handful of things.

00:31:19.340 We can insert Curtis Wright at any point here, by the way.

00:31:22.220 Yeah, exactly. So there's a guy named Curtis Wright, who was the medical examiner at FDA,

00:31:27.420 who was kind of, you know, the grand inquisitor. He was the one they had to satisfy in order to get

00:31:32.820 the drug approved, but also in order to get the marketing claims.

00:31:36.340 Maybe explain to folks why those two things are very important. Why is it that if you and I went

00:31:43.520 into business tomorrow to create a drug, the FDA would have to approve it from a safety and efficacy

00:31:49.760 standpoint? But then they'd also have to basically put guardrails around what we could actually say

00:31:56.940 it's for. I don't think people fully understand that dual role there.

00:32:02.240 You know, it's the strangest thing. Richard Sackler, this second generation Sackler,

00:32:05.120 is probably the most intimately appointed with or involved with OxyContin. There's a point where he

00:32:10.680 talks about how the package insert in a bottle of pills is our most potent selling instrument.

00:32:17.700 It's a strange thing, right? Because I think for the average consumer, you see that dense wording

00:32:22.460 on that and it feels like the fine print. It feels like something the doctors read. You may read it as

00:32:27.440 well, but it doesn't feel like a marketing document. But if you're the drug company, it's all about the

00:32:32.420 indications. It's all about the claims that you can make for what kinds of ailments this medication

00:32:37.360 might alleviate. And then also in terms of the competitive positioning. So in the case of OxyContin,

00:32:42.700 I'll give you a very extreme example. They didn't do any tests on the addictiveness of the drug. They

00:32:48.400 didn't do any tests on the abuse liability of the drug. But there was a kind of hypothesis that they

00:32:54.280 had at Purdue, which was because of the Compton system, you wouldn't have the kind of peaks and

00:33:00.560 troughs, a sort of wave of euphoria when a big dose of the drug hits your bloodstream, followed by

00:33:07.140 diminution and withdrawal. Instead, it's the steady, regulated, continuous flow. Their hypothesis was

00:33:15.380 that because of that, it wouldn't be addictive, and it wouldn't be subject to abuse. That that was a

00:33:21.180 competitive advantage vis-a-vis other opioid products that were out there on the market. You have this kind of

00:33:28.420 crazy stretch where they start working very closely with Curtis Wright on the approval process. Some

00:33:36.940 strange stuff happens. I mean, the company said, I don't even think this is in the book, but the

00:33:40.920 company sends Curtis Wright, this is in the 1990s, the 95. The company sends him a webcam. This is like

00:33:46.980 a very early webcam, where he can talk directly with folks in Stanford. Curtis Wright starts requesting

00:33:54.580 that they send things not to his FDA office, but to his house. And at a certain point, a team of people

00:34:01.440 from Purdue travel to Maryland and get a hotel room, and they spend three days with Curtis Wright,

00:34:07.100 helping him write his reviews of their studies. Let's just pause there for a second. It's almost

00:34:14.360 impossible to imagine that happening. I'm not saying it didn't, because you've got the email proof that it

00:34:21.300 happened. I'm just saying from a matter of process, that statement is so difficult to comprehend.

00:34:29.360 How do we put that in perspective? What did other people at the FDA know at this point in time?

00:34:37.000 What do you think emboldened the Sackler leadership to do that without fear of Curtis Wright turning to

00:34:46.400 them and saying, are you freaking crazy? How does this unfold?

00:34:52.360 So it's really hard to say, and I've tried to puzzle through this. And I should say, I mean,

00:34:56.180 Curtis Wright, I got him on the phone, and he very quickly hung up. Didn't want to talk to me about

00:35:01.040 any of this. I filed a Freedom of Information Act request with the FDA. They dragged their feet in

00:35:07.140 the way that federal bureaucracies always do. So I sued them in federal court to compel them to turn

00:35:12.840 over documents to me. And I got a New York federal judge to order them to do document production to me,

00:35:18.600 thousands and thousands of pages of documents. And my first request was for all the emails of

00:35:24.620 Curtis Wright. The FDA came back and told me that all of his correspondence and emails have either

00:35:30.560 been lost or destroyed. Yeah. Which again, you couldn't make that level of malfeasance up. How

00:35:37.060 do they even say that with a straight face? I could understand if it was a sort of a document

00:35:41.380 retention thing where after a certain number of years, they eliminate stuff. In his case, though,

00:35:45.660 this is a guy who had been, he was investigated by Department of Justice investigators,

00:35:50.740 really starting in like 2002, 2003. I mean, this was somebody who was red flagged early by other

00:35:57.580 federal agencies. The notion that they would today say, it's the equivalent of saying like there was

00:36:03.320 a very small warehouse fire. It's just that box, I'm afraid that we didn't retain. It's pretty

00:36:08.780 shocking to me. So I've tried to sort of puzzle this out. There's an interesting email chain. So some

00:36:14.560 of this email has come out not through the FDA, but through federal investigations of Purdue. There's an

00:36:19.140 interesting moment where one of the Purdue officials says that he happened to bump into

00:36:24.860 Curtis Wright at a conference. This is as all of this approval stuff is happening. They talked in a

00:36:30.100 kind of a sidebar way. It was not formal. My sense is that generally speaking, the FDA process, at least

00:36:36.020 in theory, is one that is pretty formalized, right? Because you don't want too much of an opportunity for

00:36:42.540 improper influence to happen. And there's this interesting memo that the Purdue guy sends back to

00:36:47.820 headquarters where he says, you know, I got talking with Curtis Wright. It was great. We talked about

00:36:50.620 the whole OxyContin thing. He indicated that he would be open to other such informal exchanges in

00:36:56.400 the future or something to that effect. So I don't know. Wouldn't the Occam's razor response be the

00:37:02.440 following? Given that a year after leaving the FDA, Curtis Wright is now employed by Purdue Pharma,

00:37:08.460 isn't the only obvious explanation here that there was a quid pro quo, a very clear and direct quid pro quo

00:37:15.200 made between Purdue and Curtis Wright? The former federal prosecutor, longtime federal prosecutor

00:37:22.640 from the Western District of Virginia who prepared the biggest case against Purdue and spent years

00:37:29.220 pouring over millions of pages of documents and looked really hard at Curtis Wright. He told me on

00:37:34.440 the record, this guy is pretty careful about what he says. And he told me on the record, I think a deal

00:37:40.040 was made. He said, I can't prove it, just my opinion, but I think a deal was made. When you look at the

00:37:44.540 totality of the evidence, it seems hard for me to believe any other, I mean, he's saying exactly what

00:37:49.720 you are, you know, any other explanation. I don't know that I need to go that far. And here's why.

00:37:55.220 I don't think Purdue even needed to say, hey, make this work for us. And there might be a job for you on

00:38:01.040 the other side. And this is where, from a policy point of view, this gets really hard to regulate,

00:38:05.860 right, is that the FDA is full of overeducated, really smart people who are making government

00:38:12.000 salaries. And they have the unglamorous task of working on these approvals. And on the other side

00:38:19.500 of the table is this huge multi-billion dollar industry where you can make a lot of money and

00:38:27.840 where there's a great deal of interest in former FDA officials, both in having them come and work at

00:38:34.100 the pharmaceutical firm because it's useful in a whole bunch of ways. But also, I would argue,

00:38:38.460 I think there's probably a great deal of interest in having the FDA officials that you're talking to

00:38:42.700 know that someday there might be a job for them. And that's this hard thing because it's not

00:38:49.060 corruption in an explicit quid pro quo sense. It's not corruption in a way that's actually all that

00:38:54.400 easy to police. Because if you're the FDA, what do you do? I mean, do you say, okay, we're gonna have

00:38:58.080 cooling off period, you know, once you leave the agency, how long? A year? Three years? At what

00:39:04.800 point do you start losing talent because people don't want to be locked up? I don't mean to suggest

00:39:08.840 for a second that these are easy questions, but I also think there's what I would call a kind of soft

00:39:13.980 corruption that pervades this whole process. And I don't think it's unique to Curtis Wright. He's a

00:39:18.280 very extreme example. But what you get is in his case, as you said, he goes a year after OxyContin is

00:39:24.820 approved. He goes and works at Purdue for three times his government salary. To your point about

00:39:29.960 the marketing claims, there's a line in the original package insert for OxyContin that says

00:39:35.560 the Conten seal is believed to reduce the abuse liability of the drug. And that's a weird thing

00:39:44.680 to have in a package insert in general. It's a great marketing claim, but it's like is believed

00:39:49.620 doesn't seem very scientific necessarily. What was the basis of that belief,

00:39:55.600 the scientific basis? Was there a study that was cited? Was there an experiment that was done? I mean,

00:40:00.940 it wouldn't be hard to have studied these things. There wasn't one. No. In this case, what it was,

00:40:06.140 was it was this conjecture that because of the Conten system, you're not getting the high highs and the

00:40:11.020 low lows, and therefore it would make it less prone to abuse than other drugs. The real measure of

00:40:17.840 how compromised this line was is that to this day, nobody will admit writing that line.

00:40:24.380 So Curtis Wright has been asked about this and he said, oh yeah, it wasn't the FDA,

00:40:27.300 it was Purdue Pharma. The Purdue Pharma officials who were there say, oh, it wasn't us, it was

00:40:31.660 Curtis Wright. But I mean, to me as a consumer, right, the idea that the FDA is working so closely

00:40:36.120 with a drug company that literally you don't know where one ends and the other begins, and there's a

00:40:41.020 line that ends up in the package insert claiming that this drug is safer than other alternatives,

00:40:45.820 and nobody can tell you who wrote it. Is it 96 when OxyContin hits the retail?

00:40:51.280 Early 96, yeah. How long does it take before the unintended consequences? Because there's really

00:40:59.040 two unintended consequences here. I guess the first is people who probably would be better served with

00:41:06.700 another form of pain control are instead using this drug. That would be one unintended consequence.

00:41:12.440 That's one that Purdue would not be against because that's simply more market share.

00:41:17.400 And then there's the unintended consequence that everyone, including Purdue, would presumably not

00:41:21.900 want, which is you start to kill your customers. Sort of the tobacco company problem, right? Like to

00:41:26.800 have an addictive product with no termination of use is wonderful if you just could figure out a way

00:41:34.880 to keep the customer alive. So what are the canaries in the coal mine with respect to these

00:41:40.060 problems? And how are they handled? I mean, I think in some ways, it's probably

00:41:44.820 useful to start with what the official story was, which is that the drug's released in early 96.

00:41:50.540 And according to sworn testimony by several senior executives at the company and by Richard Sackler,

00:41:59.140 they had no inkling that there was any kind of a major problem for four years. There were four

00:42:04.040 blissful years where they got lots of letters from pain patients saying, you know, you've given me my

00:42:09.680 life back. And there was no real sense at all that there was any kind of a problem. And it's only in

00:42:15.280 early 2000 when the United States attorney for the state of Maine writes a letter to thousands of

00:42:21.560 physicians saying this drug, OxyContin, is really dangerous. Actually, it's killing people. People are

00:42:27.160 overdosing. We've got a real problem here. And there's a crime problem associated with it.

00:42:30.980 And a little bit after this time, the chief medical officer, Paul Goldenheim, the chief medical officer

00:42:36.380 of Purdue Pharma, is brought in front of Congress, right? And he's asked questions about this. What

00:42:41.440 does he say? Same thing. He says we had no inkling that there was any kind of big problem until this

00:42:48.240 hinge point, which is when this U.S. attorney writes this letter in 2000. The other thing they say is that

00:42:53.720 they say, oh, we read about it in the press. We read about these problems in the press. And for me,

00:42:58.100 as a journalist, this was funny because I've written about a lot of companies doing bad things

00:43:02.040 and reporters like to take credit where they can get it. But generally speaking, if a company is

00:43:06.320 doing a bad thing, they don't find out about it because they read about it in your article. They

00:43:11.240 usually know a long time before the rest of the world does. There was something about their

00:43:15.660 explanation that always seemed, just on its face, seemed a little fishy to me. When I dug into it,

00:43:21.640 got a bunch of documentation. What I learned is it was a lie. They knew really early on.

00:43:28.680 How bold-faced a lie was that? Let's use Goldenheim as a specific example. So in 2000,

00:43:34.980 he's giving sworn testimony that we had no clue this was going on. What did his emails from the

00:43:40.940 late 1990s suggest? That they did. You name it. There's all kinds of back and forth about

00:43:46.520 these drugs. There's another sort of associated lie that they told, which is that there had never been a

00:43:50.760 problem with MS content, which also is a lie, a lie that was told under oath. When in fact,

00:43:55.860 there's all kinds of back and forth about that. But you've got very, very senior people, including

00:44:00.720 Goldenheim, emailing about the fact that there's an abuse problem. Pharmacies are getting robbed.

00:44:07.160 People are talking about the street value of the drug. There was a media advisory group that was

00:44:13.140 brought in to do interviews with these senior officials. There are literally emails in which some

00:44:17.300 of these senior officials who later claimed that nothing was said will be emailing about it. And

00:44:21.900 then they'll say, should we have all this chat on email? It's maybe not a good idea for us to be

00:44:26.020 having these conversations on email. You have a very clear awareness that there's a problem.

00:44:30.100 And if you back up for a second, part of the reason OxyContin did what it did, I would argue it

00:44:35.240 changed the way in which these drugs are prescribed as a category of drugs, is that they had one of the

00:44:40.520 biggest marketing forces ever. And they sent out hundreds of sales, something like 700 sales reps

00:44:46.520 to fan out across the country, meeting with thousands and thousands of physicians. That was

00:44:51.400 how they kind of got the message of OxyContin out there. But those are the canaries in the coal mine.

00:44:56.840 There's a story I tell in the book about a guy named Steve May, who was a Purdue sales rep in West

00:45:03.040 Virginia. It's 99. So this is like before, according to Goldenheim, they didn't know anything

00:45:08.900 at this point. It's 99. Steve May had this one doctor. They're really big prescribers. They would

00:45:14.780 call them whales, to use the vernacular of a Vegas casino for a big gambler. Because if you had a big

00:45:20.660 prescriber, that was great for your bonus if you were a sales rep. So Steve May had this whale. He

00:45:26.640 went to call on her, which he would do from time to time. She was upset when he showed up and he asked

00:45:31.760 her what the problem was. And she said she had a young relative, a young girl who just died of an

00:45:36.260 OxyContin overdose. So there you literally have an OxyContin sales rep going out and meeting with a

00:45:41.760 doctor who's a big prescriber and finding out that her relative has died from an OxyContin overdose.

00:45:47.740 And all those reps are writing these encounters up in notes and sending them back to headquarters.

00:45:53.180 So I think what I was able to substantiate in the book at some length is that it's clear really early

00:45:58.480 on there's a problem. I think from as early as 97. So that's just a year after the drug

00:46:02.760 is released. And word is coming back into the company. And those discussions are not just

00:46:08.520 happening at low levels. They're happening at high levels. I think what happens in 2000

00:46:12.340 is it just becomes impossible for them to deny it anymore. It's like at that point,

00:46:17.040 the sort of head in the sand won't work as a strategy. So then you need to pivot. You need to say,

00:46:21.240 okay, there is a problem. Here's our spin on it.

00:46:23.900 And that spin, of course, became, these are really bad people. We've created a miracle

00:46:30.800 breakthrough product that helps millions of people. But there are these derelicts who abuse

00:46:36.600 this product and are jeopardizing it for everybody else. We really need to ramp up the enforcement of

00:46:42.280 those people. What was proposed as the remediation for the problem?

00:46:48.000 It was a bunch of things, all of which were very much along the lines of what you're talking about.

00:46:52.800 The suggestion was, there's nothing intrinsically dangerous about the drug.

00:46:57.380 I should say the level of denial here is pretty impressive. But I mean, the Sacklers,

00:47:00.640 even today, argue that instances of iatrogenic addiction to OxyContin, where it's prescribed to

00:47:09.100 you by a doctor for a legitimate condition, and you take it as instructed by the physician,

00:47:14.220 are vanishingly rare. That's like a block that they have where they can't really acknowledge,

00:47:18.820 even today. Now, do we know what that true number is? If we say, and I'm being a bit perhaps overly

00:47:25.180 simplistic, so feel free to make this more realistic. But if we say there are three buckets

00:47:30.380 in which a patient came across OxyContin, bucket one would be, and this excludes the cancer patient.

00:47:36.720 So I want to take the end of life cancer patient out of the equation for a moment. So if you talk

00:47:40.560 about patients who are not terminally ill, who have become exposed to and or addicted to OxyContin,

00:47:45.100 entry path number one is the individual who is recovering from surgery. They are by their actual

00:47:52.960 doctor, who is a legitimate doctor given a prescription for a reasonable quantity of

00:47:58.020 OxyContin that should get them through the perioperative period. Path number two is, by the way,

00:48:03.480 you can get to path number two from path number one. So these are not independent paths, but path

00:48:07.440 number two is the sham doctor, the doc in the box who's prescribing this stuff from one state when

00:48:14.200 you're in another state doing it online or running basically the revolving door clinic where you

00:48:20.540 just come in, you ask for what you want, you get a prescription, you go out the door provided you

00:48:24.400 fill it at a pharmacy a couple hundred miles away. So they're a doctor only in legal terms, but they're

00:48:30.480 certainly not a physician in any reasonable sense of the word. And then path number three is the

00:48:36.180 illicit acquisition of OxyContin through a stolen channel. So much in the same way you would buy any

00:48:42.860 illegal drug, you're simply buying OxyContin. Do we have a sense of the relative distribution of

00:48:49.320 paths one, two, and three? No, it's very hard and in fact impossible to parse it out. And I also think

00:48:54.920 it's something that's fluctuated a lot over time, but you do get these little data points that I think

00:49:00.600 are illuminating. And I'll give you two. These are honestly like two of the more shocking things

00:49:05.360 I discovered in my research, but it's hard because it's a little complex. And so sometimes I think

00:49:09.620 from the cheap seats, it's like hard to appreciate the gravity of this. So Purdue sells OxyContin,

00:49:15.860 they release it in 96. Right away, people realize that that contin seal, you can override that just by

00:49:23.100 crushing the pills. So you can chew them, you can grind the pill, you can dissolve it in water after

00:49:28.900 you've grinded and shoot it if you want intravenously. There's actually a warning on the models telling you

00:49:34.340 not to crush the pills because if you do, you could get a potentially toxic dose of OxyContin. So

00:49:39.180 in a weird way, that functions as a kind of inadvertent how-to. I think that's significant

00:49:43.840 for at least maybe for all three of the buckets you're talking about, because you get people who

00:49:48.780 are just opportunistic drug users looking to get high. I certainly have interviewed a lot of people

00:49:55.120 who say that heroin was scary, you bought it on the street, you shoot it with a needle, that they were

00:50:00.720 looking to get high. It was like a party drug in high school, OxyContin was. But there was something

00:50:04.940 reassuring about the fact that it had been approved by the FDA. You know that even if you bought it from

00:50:09.980 a dealer, at some point, this entered the stream of commerce, you know, there was a doctor writing

00:50:14.520 a prescription. You also have people who are prescribed the drug by a doctor, and it doesn't

00:50:19.000 work for as long as they think it will, or they find themselves just kind of in its grip, they want

00:50:23.100 more. And some of those people actually convert to the immediate release thing, what they find is they

00:50:27.100 don't want to wait. And so they'll end up chewing the pills because it relieves their pain faster,

00:50:33.140 is what they'll say. So you get different ways of getting there, but the pill can be crushed.

00:50:38.840 That's 96. In 2010, Purdue rolls out this reformulated version of OxyContin that they've

00:50:46.280 worked on for years. It's basically, you can't crush it. It's like a gummy bear. If you try and break

00:50:52.180 it up, it just kind of goes chewy and gummy on you. There's an interesting backstory there,

00:50:57.080 questions about why it took so long to roll that out. There's an interesting aspect of the timing,

00:51:01.200 which is that the original patent on OxyContin were about to run out. So just in the nick of time,

00:51:07.040 they have this line extension basically in the form of the reformulated drug.

00:51:10.180 Well, it goes one better than that, doesn't it, Patrick? Because at the time, they even basically

00:51:15.880 declare that their old formulation is probably unsafe, which is really a great dig at the competition.

00:51:21.980 Which is, as we're about to roll this thing off its patent life, we want to make sure that nobody

00:51:27.620 else uses it either as we reignite a new patent on a new drug, which is infinitely safer in the

00:51:33.100 presence of our old dangerous drug. I mean, again, that would be the skeptical view of things.

00:51:37.400 And I think in this case, the skeptical view is right on. And in fact, there are emails going back

00:51:41.280 years and years and years talking about how if they came up with a kind of abuse-proof,

00:51:45.980 tamper-proof formulation, that would function as a line extension, that that was the reason they were

00:51:50.240 doing it primarily was to extend the patent life. The surpassing cynicism of the idea that

00:51:56.680 having for, at that point, 14 years said, oh, it's perfectly safe, it's perfectly safe,

00:52:01.160 it's perfectly safe, the original formulation, they developed their new formulation and then

00:52:04.640 they turn around and say, but we wouldn't want to see any generic versions of the original

00:52:07.280 formulation because in fact, it's not so safe after all, is amazing. And it worked and the FDA obliged.

00:52:12.700 But so here's the statistic that really blows my mind. 2010, the reformulated version is rolled out

00:52:19.420 and the old pills, they kind of disappear from the shelves and the new ones take their place.

00:52:26.820 And what I discovered was a study, an internal study that found that in 2010, when this happened,

00:52:33.140 for the 80 milligram pills, which was the biggest and most profitable pills on the market,

00:52:38.520 also the most popular on the black market, sales nationwide fell 25%. I can't tell you

00:52:45.440 proportionately who's in what bucket. What I can tell you is that up to 2010, I think it's safe to

00:52:52.000 intuit 25% of the sales of 80 milligram OxyContin were going to people who were abusing those pills,

00:52:59.960 you know, in one way or another, which is astonishing to me because, I mean, that's a non-trivial

00:53:05.140 part of the company's profits. So on the one hand, it's, they don't want their patients,

00:53:10.680 their customers to die. On the other hand, there is a sense in which even as they were decrying the

00:53:15.120 black market, like the black market was helping to pay the bills at the company.

00:53:19.840 The thing that I really wish we could have an insight into is, even if you take the most charitable

00:53:24.900 view of things, which is that every person's first interaction with OxyContin was through path one,

00:53:30.900 that is to say you were legitimately prescribed this for non-cancer pain by a legitimate caring,

00:53:39.820 understanding physician. But then a subset of the people left bucket one for bucket two

00:53:46.300 or bucket three as their appetite for the drug grew in the absence of an indication versus how

00:53:52.080 many people de novo show up in bucket two and bucket three drug seeking. The fact that we don't

00:53:56.880 know that makes this very difficult and creates this moral ambiguity around it, which frankly is

00:54:03.220 a bit of a distraction from the real culpability here. Oh, that's interesting. I mean, I think the

00:54:09.100 fact that we don't know it and that it's impossible to know, combined with the fact that when you look

00:54:14.260 at, you know, this is a favorite of Purdue and the Sacklers, but like when you look at toxicity

00:54:18.040 reports on people who die, people who overdose, it's often not just OxyContin in the bloodstream,

00:54:23.960 right? It's often mixed with other things. There's this whole exercise of parsing, like

00:54:30.300 moral and legal parsing that they do, which I have to say for me, just as someone who's trying to live

00:54:37.060 a righteous life, it's always amazing to me because I always just think, I can't imagine,

00:54:40.800 how do you get there? At a certain point, so many people have died from your product. It's this kind

00:54:46.920 of incredible symphony of rationalization that happens. On your point about, you know, everybody,

00:54:53.780 you know, ideally you'd have a situation which everybody sort of enters through bucket one.

00:54:57.720 Let me give you the other statistic, which is that we'll get to this, but Purdue Pharma is now

00:55:02.040 in bankruptcy. And in the context of the bankruptcy, there are many, many, many creditors who have a

00:55:07.160 claim that they'd like to exert against what's left of the company. And one of them is United

00:55:12.460 Health. United Health had this fascinating filing where they were talking about the idea that they

00:55:17.960 should have a piece of the pie, such as it is. And we'll leave aside for a second whether a big

00:55:22.940 insurer should be there in line along with all these people whose lives have been ruined by the

00:55:28.820 drug. What was interesting is that they said they ran a study. I don't remember how many years it was,

00:55:34.360 but it was over the course of something like seven or eight years. They looked at people who had

00:55:40.140 United Health plans and who were prescribed OxyContin or another Purdue opioid and subsequently

00:55:48.880 diagnosed with an opioid use disorder. I think that would actually be a kind of a smaller subset

00:55:53.660 because you literally have a diagnosis of an OUD. And they said that for that subset,

00:56:00.080 prescription from a doctor, subsequent diagnosis, just United Health over seven or eight years,

00:56:06.160 they said the number was in the hundreds of thousands. I mean, I'm sure it would be in the

00:56:10.640 study, but what percentage of people was that who were initially given a prescription? Was that

00:56:14.600 10%, 20%, 50%? Oh, that I don't know. That's interesting. I don't know. It probably was. It was

00:56:21.120 not revealed in the filing to the bankruptcy court. That would be interesting because that would actually

00:56:25.600 shed great light on this issue. It would. The thing that's interesting is that it remains a

00:56:30.260 talking point, certainly for the Sacklers and their legal counsel, that it's virtually impossible if

00:56:35.800 you're a pain patient and you're prescribed the drug by a doctor and you take it as directed to

00:56:39.900 become addicted, to put that side by side with this hundreds of thousands number is extraordinary.

00:56:45.260 Even if you build in a discount where you say, okay, well, some of those people probably did,

00:56:50.360 you know, some of those were fraudulent docs or fraudulent patients or what have you,

00:56:54.480 you still end up with a really huge number of people who have become hooked on the drug

00:56:59.260 in an iatrogenic context. You know, I have a real personal history with this,

00:57:04.220 which I'm sure you'll appreciate. I wasn't sure I was going to tell you this story,

00:57:07.480 but I think it's appropriate here. In some ways, I feel very lucky to be sitting here

00:57:11.000 having a discussion right now as opposed to being dead. A little over 20 years ago,

00:57:15.000 when I was in my last year of medical school, I had a really bad back injury. Sort of hurt it

00:57:20.240 kind of acutely and for two and a half weeks just ignored it. But the pain grew more and more

00:57:24.900 debilitating. I remember I was doing a rotation. I couldn't even sleep. I had to get the residents

00:57:31.000 to inject Tordal into my thighs just to allow me to have enough of an inkling to be able to sleep

00:57:36.260 for a while. Finally, at some point, I just agreed to go get an MRI and look. And sure enough,

00:57:41.120 there was a really bad herniation in my lower back and about a five centimeter fragment of disc

00:57:46.440 had broken off on the left side and it floated down the canal and it was sitting on the S1 nerve

00:57:51.140 root, which is what was causing this almost comical amount of pain. I say comical now because

00:57:55.500 it's hard to even describe. There's nothing funny about it. So I underwent surgery the next day,

00:58:00.580 but surgery didn't go well for a number of reasons, but the surgeon operated on the wrong side.

00:58:05.460 So I woke up from the surgery in terrible pain, but also with a new complication on the other side.

00:58:12.560 This resulted in a number of follow-up procedures initially aimed at correcting the first problem.

00:58:18.880 But before I knew it, even once the structural problem had been fixed, the pain was so bad that

00:58:25.500 I finally relented and agreed to take pain medicine. I had been horribly petrified of taking

00:58:32.100 anything beyond NSAIDs. So what was the first drug? This is the year 2000. So what's the first

00:58:36.700 prescription I get? It's for 20 milligrams of OxyContin to be taken, I believe, twice a day.

00:58:41.920 I think you take 20 in the morning and 20 in the afternoon or evening or something like that.

00:58:45.620 You can probably imagine where this story is going, Patrick. How much OxyContin do you think

00:58:49.580 I was taking within four months? Tell me.

00:58:52.200 Almost 400 milligrams a day. So again, maybe for the listener who doesn't know what that means in

00:58:57.340 context, that would be enough to kill an entire family of drug-naive people. 400 milligrams would

00:59:04.300 kill mom, dad, Susie, Bobby, Sally. They would just stop breathing. So it didn't take long for me to go

00:59:10.500 from 40 milligrams a day to 400 milligrams a day. And there are a couple of things about this that

00:59:15.720 are interesting. The first is that was all prescribed by a legitimate doctor who was not

00:59:21.620 at all an expert in pain management. This was a surgeon who had already demonstrated gross

00:59:27.300 incompetence in not operating on the right side. No one was monitoring how much of this drug I needed.

00:59:33.620 The dose just kept going up and up and up. I was very fortunate at the time to be dating

00:59:39.960 an anesthesiology resident. So she was about three or four years older than me, actually probably in

00:59:44.500 her last year of anesthesia. And she herself was actually interested in pain management. So she would

00:59:48.900 go on to do a fellowship in pain management. She was a bit troubled by how much of this drug that I was

00:59:53.400 on. And that sort of got me thinking, how the hell did I get here? Because it happened so quick.

00:59:59.160 One minute you're like, I never, ever, ever want to take one of these drugs. And then the next minute,

01:00:03.620 you're basically in a constant haze. There was no moment that I wasn't high.

01:00:08.680 The turning point for me came when I realized that I couldn't differentiate between the pain relief

01:00:16.200 and the high. In other words, I realized I was probably taking the drug to avoid the psychological

01:00:22.600 pain, which at the time I was pretty convinced I'd never walk again. This was a one-year recovery

01:00:28.340 process, but the first three months I couldn't walk. That basically shattered all of my dreams.

01:00:33.380 I was no longer going to be able to be a surgeon. I believed, let alone be an active,

01:00:38.900 healthy person that I'd been all my life. And so I was actually taking this drug just as much to blunt

01:00:44.800 that grief as I was taking it to blunt the pain. And finally, in the fall of that year,

01:00:52.100 I just decided, I don't want to do this anymore. I never imagined I would overdose. That's the other

01:00:56.980 thing, by the way. It never even crossed my mind that I could get to a point where I would stop

01:01:00.540 breathing. But I just thought, no, I can't do this anymore. So I said to my girlfriend, I said,

01:01:05.100 I'm going to stop this cold turkey. And she said, you absolutely can't do that. The withdrawal from

01:01:12.140 this will kill you just as much as this drug will kill you. You need to be on nortriptyline,

01:01:17.240 morphine. I mean, she rattled off all the drugs I would need to take to taper off. But I was a stubborn

01:01:22.600 kid and I just stopped cold turkey. And the next three weeks of my life would be about the most

01:01:30.760 miserable three weeks of my existence. I certainly hope I don't have another three weeks somewhere

01:01:36.040 down my life that will be that bad. But here's the thing that is interesting. I'm not telling this

01:01:41.000 story to, for a moment, suggest any superiority. Like, look at me, I was able to come off this drug.

01:01:47.520 What my point is that what I've learned about addiction since then would suggest that I'm simply

01:01:52.280 biologically lucky. In other words, I truly believe that the neurotransmitters in my brain

01:01:58.960 are not wired the way that someone who in that exact situation would have become a lifelong addict.

01:02:05.560 That's why I say I'm very lucky. I'm not lucky because I have willpower. I'm lucky because that

01:02:12.140 chemical didn't put a hook in me the way it would in others. So in other words, I had become

01:02:16.580 physiologically dependent on it. And that's why I went through withdrawal just as anybody would.

01:02:21.400 But I'm really lucky I managed to escape this drug. It's interesting. I was still

01:02:26.240 deathly afraid of the drug after the fact. Only seven years later, when I had a really,

01:02:32.380 really bad dental issue, would I ever touch another Percocet in my life, which of course is a fraction

01:02:38.700 of the drug. And I remember being really worried, like what's going to happen? Is this going to escalate

01:02:44.400 into massive use? And fortunately it didn't. I needed Percocet for like a week until I had a tooth

01:02:51.800 extracted. I just stopped it and that was fine. It paradoxically gave me more empathy than self

01:02:59.240 righteousness over the people who became addicted. I don't know why. That's not obvious why that would

01:03:05.800 be the case. I think I just sort of believed that there are some of us who don't get addicted to these

01:03:11.900 things, even when exposed, but there are enough people who do. And I don't know what that number

01:03:16.580 is, right? And to your point, I don't know that we can ever know that number, but I agree with you

01:03:20.580 that that doesn't remove the moral obligation of the people that were involved in exposing people

01:03:26.520 like me and people much less fortunate than me. I would imagine that part of the reason that it gave

01:03:32.060 you a sense of compassion for those whose experience has turned out much worse is that it does sound

01:03:38.900 as though you encountered. And I've talked to so many people whose lives have been upended by this

01:03:42.920 drug and other opioids. It's often like there's a kind of undertow. There's just this sense that

01:03:47.940 you're suddenly in the grip of something. You managed to get out of the grip, but it sounds like even you

01:03:53.280 were in terms of the physiological dependence and the idea that you were titrating up so fast.

01:03:58.240 That upward speed was unbelievable, Patrick. Unbelievable how quickly a tolerance developed. And by the way,

01:04:04.860 it's total bullshit to say you don't get high from a time-release drug. I don't know what it's like

01:04:09.400 to take heroin. So I'm sure compared to heroin, it's blunt, but there is an absolute blast off high

01:04:16.320 that came from those mega doses of that drug. What's so intriguing to me though about your story

01:04:22.320 is actually the doctor, the idea that you have a surgeon who writes you the prescription. And part of

01:04:29.840 what's so fascinating is that the drug companies, Purdue and the other companies,

01:04:33.400 argued from the beginning that doctors don't know enough about pain management. They haven't

01:04:38.240 gotten the training. And there was some truth to that. But the weirdness of it is they then rush

01:04:43.540 into the vacuum and they say, we'll provide that training. We'll do that education. The catchphrase

01:04:50.360 for OxyContin early on was that it's the drug to start with and to stay with. The first part of that,

01:04:55.820 right, is it's like, this isn't some nuclear solution you keep on the top shelf where you would try

01:04:59.860 other courses of therapy. And only when those fail, do you resort to it. It's the first thing

01:05:05.080 you should administer. And then it's the one to stay with, meaning you can just keep taking it for

01:05:10.560 chronic pain conditions year in, year out, even if you have to keep titrating up. And it was a core

01:05:16.900 belief that the company, Richard Sackler felt very strongly about this, that there was no, you know,

01:05:20.680 what he described as no ceiling effect with OxyContin. That in fact, you could just keep taking

01:05:25.820 greater and greater doses, which you would need to as your system accompanies itself to it.

01:05:30.700 And then you have the pharmaceutical reps who are meeting with doctors like your surgeon

01:05:35.400 and are heavily incentivized to get those docs to titrate up. That's always the message because

01:05:42.820 the profits, and in fact, even the bonuses for the pharma reps are all based on volume of the drug

01:05:50.480 that's sold and prescribed. It's just funny because, you know, hearing your anecdote from

01:05:55.460 your side, what I see on the other side is this sort of perfect storm of scenarios where when you're

01:06:02.060 thinking about like, do I go cold turkey? Do I taper off? Should I be taking morphine? You're having

01:06:07.500 those conversations with your girlfriend because the guy who prescribed you the drug probably doesn't

01:06:12.660 know how to explain to people how to get them off. I mean, you have this crazy situation in which you

01:06:16.920 have a generation of doctors who learn how to on-ramp their patients with these drugs and never learn

01:06:25.440 how to off-ramp them and actually kind of don't necessarily have any interest or inclination.

01:06:30.500 And if you talk to people who've had these experiences, they'll say, I went back to the

01:06:33.860 surgeon who wrote me the original script and I said, I'm having problems here. And they say,

01:06:39.600 whoa, whoa, whoa, I'm not an addiction specialist. When you look at all those circumstances and you kind of

01:06:44.320 extrapolate from that story you just told, it's not surprising to me to think that there are many,

01:06:49.080 many, many people who had a similar situation and ended up in very dire straits.

01:06:54.800 You made me think of something else, which I should have mentioned earlier, which is there's

01:06:57.500 another reason I was very, very fortunate was to have a girlfriend at the time who is not just an

01:07:04.480 anesthesiologist, but someone who's a year away from doing a pain fellowship. She actually got me in

01:07:10.020 to see a pain expert at Stanford who I think really is the guy that saved me. Because remember,

01:07:17.780 it's one thing to sort of quit this drug cold turkey, but I still had pain. Getting off the

01:07:22.880 drug was one problem, but addressing the pain was another. And I think only because of this other guy

01:07:27.720 whose name was Sean Mackey. I don't even know if he's still at Stanford, but he was able to treat me,

01:07:34.840 I think appropriately, right? So that meant doing a lot of injections to begin and sort of cool things

01:07:39.660 off that had flared up using a drug called Neurontin, which is not addictive, incredibly

01:07:44.720 benign. It is sedating. So that's a drawback to deal with the neuropathic pain and then using very

01:07:49.980 strong NSAIDs. So at the time, Vioxx was a drug that basically saved me. And that allowed me to break

01:07:56.500 the cycle of pain and do enough PT such that a year from when that whole thing began, I was actually in

01:08:02.640 my surgical residency and free of all pain medication, meaning free of the Neurontin and free of

01:08:07.560 the Vioxx. That part of the story also speaks to the incredible fortune that I had that many people

01:08:15.080 don't have. And maybe had I not had it, there still would be a different ending, right? It still might

01:08:19.960 have been that, well, after three months of going cold turkey, I had to go back because there was no

01:08:23.760 alternative. And when I was in my residency, I was still amazed at how ignorant we were as surgical

01:08:29.280 residents of pain management. I mean, completely ignorant. There was absolutely no teaching of

01:08:37.440 this subject matter. Something that I learned that was very simple was studies had demonstrated

01:08:43.300 that before you do an incision on a patient, if you inject Marcane, which is a long acting sodium

01:08:50.640 channel blocker, like a Novocaine type thing that the dentist would put in your teeth. So you have

01:08:54.200 lidocaine, which is short acting, Marcane, which is long acting. If you inject the incision site with

01:09:00.680 Marcane before you cut, you wait a moment, you then make the incision. And then immediately following

01:09:07.620 surgery, you put the patient on a pretty aggressive dose of NSAIDs. Many patients can actually avoid

01:09:14.200 narcotics postoperatively for the incisional pain, which is the dominant source of pain.

01:09:19.540 And I remember thinking, why aren't we doing this with every patient? I got into an argument with one of

01:09:25.280 the attendings because I was about to do an operation and I went to do this. And he said,

01:09:28.860 come on, come on, come on. That's going to take five minutes. You've got to put that in. And then

01:09:32.700 we have to sit here and wait five minutes with our dicks in our hands while it sets in before you cut.

01:09:36.880 No, no, no, no. We don't have the time for that. And I remember thinking, really? We don't have five

01:09:42.080 minutes? You know, it was shocking. Yeah. I think in a weird way, I'm not a doctor, right? I say this

01:09:48.800 coming from the outside, but having done a little bit of an anthropological bushwhack through this world

01:09:55.360 over the last few years, you go back to what we were talking about earlier, where you have the

01:09:59.180 Sackler brothers in the 1940s and 50s saying, wouldn't it be beautiful if someday there was

01:10:05.680 just a pill you could take for everything? And particularly Arthur Sackler kind of trying to

01:10:10.940 sort of intermingle medicine and commerce in ways that I think ended up being more profound than

01:10:17.200 anybody could have probably recognized at the time. From the outside, I think that one of the

01:10:21.940 ingredients that gives you the opioid crisis is actually that idea of, we want to waste five

01:10:27.880 minutes. We need to get our patients in and out. Time is money. And I've interviewed doctors who talk

01:10:34.120 about how they felt duped, how when the Purdue sales reps started flogging OxyContin, if you're a

01:10:41.580 doctor, you encounter patients who are in pain, you want to relieve that pain. You know, it's often, it's in some

01:10:46.360 ways inherent to why you chose to do this in your life, right? Is you want to bring relief to people

01:10:51.560 who are suffering. And suddenly there's this medical innovation, which you're told is like a panacea.

01:10:58.580 It can relieve that pain and has virtually no side effects. And people can take it forever. And there's

01:11:05.600 no dosage sealing. I've talked to people who've said just earnestly, that was a siren song I was all too

01:11:12.480 ready to listen to because it filled a need in my therapeutic arsenal. And of course it ended up

01:11:19.980 being more complicated. But I also think that when you think about the way in which American medicine

01:11:24.360 is structured, the idea that you have a patient who's in pain and you say, I'm going to write you

01:11:29.920 a prescription for 20 milligrams of OxyContin, be on your way. I never have to see you again. I'm not

01:11:36.320 really going to give any thought to how this is working out for you two weeks from now or two months

01:11:40.720 from now or two years from now. I think that that notion that five minutes is money. That five

01:11:46.320 minutes is five minutes you're not spending with the next patient. It's a longer line in the waiting

01:11:49.900 room. I think those kinds of structural considerations were part of what allowed Purdue

01:11:55.280 and other opioid makers to kind of snow the medical establishment as effectively as they did. Where if you

01:12:00.600 look at the prescribing levels for these drugs, with the introduction of OxyContin, they just suddenly

01:12:05.740 start climbing in this really dramatic way. And you would think that there would have been more

01:12:10.340 skepticism that it would have been slower growth. But I do think there was a sense in which it sort

01:12:14.360 of filled a number of needs. And that was what allowed it to take off the way it did.

01:12:19.680 Well, it also seemed to become very politically correct in the sense that they somehow managed

01:12:24.060 to infiltrate the AMA. I mean, one of the other memories I have from the early days of residency was

01:12:29.540 how all of a sudden a new vital sign emerged. So vital signs are by definition objective. So they are

01:12:36.640 things that can be measured for which there is no ambiguity. Temperature, pulse, respiratory rate, blood

01:12:42.700 pressure. But then a fifth vital sign got introduced, which was pain. A subjective measurement on a scale

01:12:48.600 of one to ten. And there were laminated posters on every corner of the hospital. Don't forget the fifth

01:12:57.020 vital sign. Don't forget the fifth vital sign. What is the fifth vital sign? What is your patient's pain? And this

01:13:04.000 really came from the medical community. This was a form of self-policing. So how involved was Purdue

01:13:11.940 in driving that agenda? I want to be careful about how I put this. Very would be the short answer.

01:13:19.080 But I think you have this tricky thing. It's a little bit like when I was talking about

01:13:23.360 Curtis Wright and the FDA and how there's a kind of soft corruption that happens, which is

01:13:28.860 not as glaring as the caricature-ish corruption that you would think of. I think there's a similar

01:13:34.800 thing here where you have the American Medical Association. You have all kinds of groups, groups

01:13:41.240 of doctors, groups representing patients, patients' rights, kind of pain advocacy groups. And then you

01:13:48.280 have industry underwriting a lot of this stuff. Quite a good piece in Mother Jones just recently about

01:13:55.020 the AMA and Richard Sackler was on one of these boards and you have a lot of money going to sponsor

01:14:00.900 education. I just read that Mother Jones piece and I couldn't believe that the AMA, both as an

01:14:07.300 organization and its foundation separately, are receiving money from the Sacklers.

01:14:14.380 Yeah. And then often what happens, right, is that you get these things where it's like an educational

01:14:18.360 pamphlet that they end up distributing. There's a kind of laundering that happens,

01:14:21.680 a sort of institutional laundering where industry comes up with these educational brochures or they

01:14:27.420 sponsor research or what have you. I mean, the example that I love from that story, the Mother Jones

01:14:31.920 story, was that there was one handy guide to pain and the fifth vital sign and the idea of how do you

01:14:36.860 talk to a child about the pain they're feeling? And there was an admonition to the doctors that,

01:14:41.420 remember, you've got to tell the child that no pain is not an acceptable answer. There's a continuum,

01:14:46.380 but the end of the continuum where there's no pain, you know, that's not an option. I think it's

01:14:51.900 more a coincidence of interests in which you have people who earnestly believe these things and then

01:14:56.560 are underwritten by industry and that kind of turbocharges the arguments they're making more

01:15:02.180 than it is a situation of docs being paid off to tell what they know to be lies. When you talk about

01:15:09.000 the idea of the fifth vital sign, even just that phrase, on the one hand, I think that there was some

01:15:13.900 truth to the critique that there hadn't been enough education in pain management and enough

01:15:19.360 consideration given to how you relieve patients' pain. I think as a critique, that had some truth

01:15:24.900 to it. On the other hand, when you say the fifth vital sign, like to me, that sounds more than

01:15:29.000 anything like a great marketing slogan. I don't know who'd dream that up, but it sounds like something

01:15:35.540 that an advertiser would come up with. It's catchy. It's kind of pithy. And of course, it's totally

01:15:40.900 subjective. There was a study, I couldn't give you the citation, but I remember reading this great

01:15:45.300 study where it was like the scale of one to 10 thing. What might be a seven for you could be a

01:15:51.540 nine for me, but that it actually varies regionally. You know, they found that like people in Northern

01:15:56.980 Europe, you'd exert some sort of standard amount of pain and they would say, oh, that's a four. And

01:16:02.820 then people in Southern Europe, you'd exert the same amount of pain and they would say, it's a 10,

01:16:06.260 it's a 10. You actually get these cultural regional differences in terms of people's pain

01:16:11.060 thresholds. It's hard because I do think it's a legitimate thing that people should be looking at

01:16:16.120 and inquiring about, but at the same time, it's totally subjective. And I think that again and

01:16:19.840 again, you see just the money pollute everything. You mentioned earlier that Curtis Wright effectively,

01:16:26.620 whether in a direct quid pro quo or more of just a confluence of interests, not only basically

01:16:34.060 approves this drug single-handedly for the FDA, but then ultimately winds up working

01:16:38.920 for this entity. But the other story in this one that really blew my mind was that of Lyndon Barber

01:16:45.120 at the DEA. On the one hand is, seems by all accounts to be one of the most credible voices within the DEA

01:16:53.280 to standing up to the unmanaged distribution of these drugs. And then kind of does an about face

01:17:02.200 and becomes one of the most powerful lobbying entities for the very companies. I believe Cardinal

01:17:08.780 was one of his largest clients, Cardinal McKesson being two of the largest distributors,

01:17:14.560 kind of hard to believe. But at the same time, I guess going through the, what you said earlier,

01:17:19.000 it's like, look, how long can you work for nothing as a government employee? At some point he has a

01:17:24.620 choice, which is he's going to go make a living harnessing his existing skills, but it just doesn't

01:17:29.540 feel right. I don't know how else to put it. It just doesn't sit well with me.

01:17:33.120 I don't want to sound like a scold or preachy or somebody who's holier than thou or like a Boy

01:17:38.320 Scout, because I'm not by any stretch. But it has been one of the more dispiriting things working on

01:17:43.680 this project where, you know, a lot of the time in the past I've written about crime a fair amount.

01:17:48.240 It's just kind of baked in that you're writing about a bad person doing a bad thing.

01:17:51.940 And they kind of know they're bad, usually. And there's a sort of moral clarity there.

01:17:58.220 What was so fascinating to me about this story is that I think the Sacklers are bad actors. I think

01:18:04.140 they did really bad things. And they're the focus of the story. But then around them are all of these

01:18:10.500 facilitators. And it's former prosecutors who go and work as private defense attorneys for the family

01:18:18.200 or for the company. It's former DEA officials who go and work as lobbyists for the industry. It's

01:18:25.020 former FDA officials who go and work at the company. It's folks at McKinsey. It's this whole

01:18:32.240 kind of amazing entrenched machine of people who I think in many instances don't think of themselves

01:18:39.600 as the bad guys. And in some cases, society doesn't think of them as the bad guys. One of the characters

01:18:45.200 in my book is Mary Jo White, former U.S. attorney for the Southern District of New York. She was

01:18:50.880 Obama's head of the SEC, a woman who broke the glass ceiling. And she's represented Purdue and

01:18:56.160 the Sacklers for years and is totally a handmaiden to them. So it's a thing that I've kind of wrestled

01:19:01.580 with personally. I'm a lawyer by training. And I know that there is a sort of, it's very fundamental

01:19:07.060 to the ethos of the profession that the lawyer isn't the client and that we shouldn't necessarily

01:19:11.320 transposed the moral stink of the client onto the lawyer. But it's hard for me when you tell

01:19:18.100 the Lyndon Barber story, there's a hundred people like that in the book who play that kind of role

01:19:23.320 again and again and again. You get these people who are supposed to be the cops, basically. They're

01:19:28.080 supposed to be law and order and they get co-opted by the money. And it's really discouraging.

01:19:33.600 And sometimes I don't get it because the money isn't even that much. I mean, when you look at

01:19:36.620 Chris Dodd and Marsha Blackburn and Tom Marino and Orrin Hatch, I mean, it's just hard for me to

01:19:43.020 look at these people and think of them as reasonable or respectable, truthfully. When I look at their

01:19:47.840 involvement in the bills that they sponsored and the positions that they took in all of this.

01:19:54.100 And when you look at the dollars that they received, they're bought so cheaply.

01:19:58.180 Yeah, that's exactly the point, Patrick. I expected that it would have taken tens of millions to have

01:20:04.540 bought those people. They were bought for hundreds of thousands of dollars. U.S. senators for sale for

01:20:11.500 hundreds of thousands of dollars? I don't understand it. So I think the thing is it's, some of it is the

01:20:17.380 money, donations and what have you. But I think there's this other thing that is more about the

01:20:23.260 revolving door, this insidious thing where the lobbyists, and the lobbyists are often people they

01:20:29.320 know. You see this with the way in which Purdue and the Sackers would use lawyers. Like Mary Jo White

01:20:34.960 is a good example, or they hired Rudy Giuliani for years, was kind of their hatchet man. And it's like,

01:20:40.580 if you were a federal prosecutor and you're investigating me, the real move is not to sort

01:20:46.180 of fight it out with you on the merits in court the way most people would. It's for me to go to your

01:20:52.840 boss, but not for me personally to go to your boss, for me to find somebody who your boss knows and

01:20:58.120 respects. And that's the person I buy off. And I send them to go and kind of make the overture.

01:21:04.060 I think when you look at these people, it's not just that they're, again, it's the sort of soft

01:21:08.180 corruption. It's not like campaign contributions. It's that scene in The Godfather where the guy's

01:21:13.360 supposed to testify in court and they get the old guy from Sicily to come and just sit in the courtroom

01:21:18.960 and it happens to be his uncle or whatever. And he sees the guy in the courtroom and he suddenly

01:21:22.880 sort of loses all his moral conviction and decides he's not going to testify. It's sort of that. It's

01:21:27.960 like being really smart and strategic about who's the right messenger. Who would we send to make the

01:21:33.120 case to Chris Dodd about why he shouldn't come after us or why he should help us in this or that.

01:21:40.600 And they're really good, really, really good at that.

01:21:43.940 And it's interesting at how, if I want to use the word, you might not use the word,

01:21:47.700 but if I want to use the word corruption, how bipartisan the corruption was, what was the bill

01:21:52.020 H.R. 4709? This is the sleeper bill, right? It's like this three page nothing burger that

01:22:00.520 basically opened the pipelines to move these drugs and put the DAA's hands behind its back. I mean,

01:22:08.780 it's a little detail, but my God, it's amazing how unopposed that bill went.

01:22:14.520 Absolutely. But some of that I think is the fact that nobody's really reading the bill. The bill

01:22:19.320 was carefully designed to look like it was sort of doing the opposite of what it was doing, right?

01:22:24.280 It's like, we're going to fight the opioid crisis. Obama signed it and who knows how closely he looked

01:22:29.980 at it. There's enough business that goes on in Washington. And I think particularly when it

01:22:34.760 comes to lawmaking, you have these members of the House and senators who are, they spend all their

01:22:39.260 time raising money. If you can make what you're doing look like business as usual, you can pull

01:22:45.320 it off. It's super dispiriting. The opioid painkiller industry spends, I think the statistic

01:22:50.500 is like seven or eight times what the gun lobby spends on lobbying in Washington. So just imagine

01:22:57.200 the kind of impact that you can have on the legislative picture. And then you see this with

01:23:02.160 a company like Purdue. You have this long period of time where all these states are trying to respond

01:23:06.720 at a state level to the opioid crisis. You know, they're trying to introduce new legislation to

01:23:11.300 shut down pill mills or go after bad docs and what have you. You have these legislative initiatives at

01:23:16.840 a state level that gets set up and Purdue finds the right state lobbyists to go to the state capital

01:23:22.420 and help neuter those bills as best they can. And we're very successful at doing that. When you have

01:23:28.660 a drug that's generated $35 billion in revenue, the amount of influence you can buy is just awesome.

01:23:34.940 What was the first shot across the bow, 2007? It's a little bit of a slap on the wrist. What led to

01:23:41.800 that? You had a couple of investigators at a small federal prosecutor's office in the Western District

01:23:48.300 of Virginia. Their community had been upended by OxyContin specifically. They started realizing,

01:23:54.520 you know, we're getting all these pharmacy thefts and crime is going up and you get people ODing.

01:24:00.560 And they started investigating. And to them, it was this kind of weird thing where they felt like a

01:24:04.280 hurricane had just like hit their town. They wanted where it came from. It came from Connecticut.

01:24:09.020 So they started investigating and they did this really amazing investigation. They spent five years

01:24:13.320 investigating Purdue. They subpoenaed millions of documents. They did huge amounts of grand jury

01:24:18.300 testimony and wanted to charge three senior executives at the company with felonies. The idea being that

01:24:26.760 these guys were not going to go to jail. Faced with jail time, they would flip on the Sacklers.

01:24:32.680 One of those federal prosecutors has said this on the record. And there's another one who's confirmed

01:24:37.640 for me that the plan was actually to target the Sacklers, if they could flip these guys.

01:24:42.380 And what ended up happening was that the company sent Rudy Giuliani and Mary Jo White to go over the

01:24:48.600 heads of those federal prosecutors to the George W. Bush Justice Department in Washington and say,

01:24:54.280 you can't go after these guys for felonies. We need to take felonies off the table,

01:24:57.920 we'll take jail time off the table. So they got overruled by their own bosses.

01:25:02.040 This was Alice Fisher and Paul McNulty?

01:25:04.480 Yeah, exactly. It's a little bit like that line in the package insert where in 2021,

01:25:08.880 I talked to Alice Fisher and Paul McNulty and said, who made that decision to tell these

01:25:13.220 prosecutors in the Western District of Virginia? And it's like-

01:25:15.760 They're each pointing at each other.

01:25:16.920 They're pointing at each other. Nobody would own it. You would think, all these years on,

01:25:21.460 pretty consequential decision. You would think that somebody might take responsibility for it.

01:25:24.720 But what that meant is that because they couldn't charge these guys with felonies,

01:25:27.860 the guys weren't going to flip. They pled to misdemeanors. So they couldn't go after the

01:25:31.180 Sacklers. The company paid a $600 million fine and pled guilty to felony charges of misbranding.

01:25:37.200 And then it was pretty much business as usual. I mean, they didn't slow down their marketing a jot.

01:25:42.460 So what changed in the last couple of years? What's led to the bankruptcy? And perhaps more

01:25:48.400 importantly, where do we stand on, what is it called? This non-consensual-

01:25:54.860 Third-party release. Yeah.

01:25:56.540 Third-party release. Yes. This seems to be a very important granting on the part of a

01:26:01.800 one White Plains bankruptcy judge.

01:26:05.160 So 2007, the company pleads guilty. The official line after that was, oh, you know,

01:26:09.960 we cleaned up our act. We had a few bad apples, but everything's okay now. But they didn't really

01:26:14.900 change a whole lot. And really all the senior folks, the three guys who pled guilty to misdemeanors

01:26:22.000 had to leave. They couldn't keep working at the company. But other than that, all the senior folks

01:26:25.940 who were involved in this stuff stayed on. Heads did not roll. And Purdue kind of kept doing what

01:26:31.940 it was doing. In 2020, the company pled guilty to a new set of federal criminal charges. And the

01:26:38.160 conduct that it pled to dated back 10 years. So if you imagine, right, you have a company that pleads

01:26:44.460 guilty in 2007. And then in theory, there's like a couple of years of good behavior. But then

01:26:49.400 starting in about 2010, they were back to committing crimes and kept at it through 2020 when they pled

01:26:55.560 guilty again. And in between those two guilty pleas, what happens is that you get all these

01:27:00.380 lawsuits. So some of these are private class action lawsuits, lawsuits brought by hospitals,

01:27:06.100 school districts, cities, states. Eventually every state in the union, pretty much, is suing

01:27:12.880 Purdue over its role in the opioid crisis. What's happening in parallel to that, which we didn't

01:27:18.760 know about until fairly recently, is that the Sacklers, starting in 2007 after that guilty plea,

01:27:24.520 they start quietly taking money out of the company. So they're just sort of siphoning money out,

01:27:29.380 100 million here, 100 million there. Over the course of about a decade, they take more than $10 billion

01:27:34.360 out of the company. 2018, 2019, you have thousands of lawsuits against the company.

01:27:41.980 Company's kind of on the ropes. And the family kicks the company into bankruptcy. They say the

01:27:45.980 company doesn't have any money anymore, which is only the case because they took $10 billion out of

01:27:50.100 it. But they say the company's bankrupt now. So all those lawsuits against the company have to be

01:27:54.540 suspended. And they end up in this bankruptcy court in White Plains, New York. Because this is the way

01:27:59.040 bankruptcy law works, they got to pick their judge. You can decide where you want to declare

01:28:02.800 bankruptcy, corporate bankruptcy. So they picked this judge who they thought would be sympathetic.

01:28:07.360 And where it gets really interesting is that by this point, roughly half of the states were not

01:28:12.500 just suing the company, they were suing individual members of the family who had sat on the company's

01:28:15.960 board. There was a move by the company and the family to say, okay, so you've suspended all these

01:28:21.900 lawsuits against the company because it's in bankruptcy, but we want you to spend the lawsuits

01:28:26.900 against the family too, even though they haven't declared bankruptcy. And the judge did that

01:28:32.420 temporarily, which is pretty controversial. There are states in which you're not able to do that.

01:28:37.080 You're not able to say to the attorneys general of half of the states, no, you cannot bring your

01:28:42.060 lawsuit. A federal bankruptcy judge in New York says to the state AG of Idaho, no, you cannot bring

01:28:49.300 your state-based claim. It's pretty exotic, but he did. And where we are now is we're sort of in the

01:28:56.720 end game where the Sacklers have made this bid, which is they want him to make that grant permanent,

01:29:02.440 where he would permanently immunize them from any litigation. The phrase for this, and it's a

01:29:06.760 mouthful, is non-consensual third-party releases. This is happening in real time. As you and I are

01:29:13.400 talking, there's a bankruptcy trial going on with testimony, but I think everybody knows how it's

01:29:18.280 going to end. Why are we so pessimistic? Why are we pretty convinced that the ruling is going to hold up?

01:29:23.780 Because the judge has kind of telegraphed where he's going with it. And because there are some

01:29:29.780 states that continue to fight effectively don't have the votes. So basically what you have is a

01:29:34.180 situation in which the Sacklers have made a proposal to, in one fell swoop, deal with all this

01:29:39.500 litigation once and for all. And they're doing it in the context of this bankruptcy proceeding, where

01:29:44.180 they say, we will pay $4.5 billion of our money to remediate the opioid crisis. We'll pay it out over

01:29:52.020 nine years. And we'll make no admission of wrongdoing. We'll give up our interest in Purdue.

01:29:58.520 We'll be granted one of these non-consensual third-party releases, where basically this judge

01:30:02.640 gets to wave his wand and say, nobody can ever sue you again. No state prosecutor, no private

01:30:09.380 plaintiff. Nobody can sue you ever again over anything having to do with OxyContin or the opioid

01:30:13.880 crisis. And I think there are a lot of states that are desperate and fighting, dealing with the

01:30:19.900 trillions of dollars in public costs that this crisis has generated. They're reeling.

01:30:25.580 They see $4.5 billion and they think, I could use one fiftieth of that. So they're inclined to take

01:30:30.860 the deal, even if they don't like it. And it's an interesting one because I think a lot of people

01:30:36.180 look at it and they feel like this wouldn't be justice. To put that $4.5 billion number in

01:30:41.120 perspective, the Sacklers still have an $11 billion fortune and they're going to pay out the $4.5 over

01:30:45.780 nine years. And it's actually not linearly weighted. The majority of that payment comes

01:30:50.700 at the end of time. So in theory, they're technically going to come out ahead if they

01:30:56.060 reasonably invest well. Yeah. I had some conversations with people who advise high

01:31:01.560 network families and invest their fortunes in the conservatively between interests and a very

01:31:06.980 conservative portfolio. They can probably expect a 5% return on that $11 billion fortune. And if that's

01:31:13.740 the case, they never have to touch their principal. Yeah. In absolute terms, it's a lot of money,

01:31:17.900 but it's, I don't think commensurate to the damage. And I think ultimately it'll be a pretty good deal

01:31:22.680 for the Sacklers. But I think that's how it's going to shake out. Now, do you think that this

01:31:28.080 accomplishes anything else? So no amount of money is going to bring back a loved one. I have several

01:31:34.000 patients whose lives have been directly impacted by this, whose children have overdosed. Kids that became

01:31:41.680 addicted to prescription pain pills. You know, in one situation, one of the kids was clean for a

01:31:48.180 number of months, if not a year, was at a party. Someone suggested he try a pill. It turned out to

01:31:55.800 be laced with fentanyl. You know how that story ends tragically. So no amount of money is going to

01:32:00.520 fix that. And so whether the Sacklers have to give four and a half billion or forfeit every dollar

01:32:05.980 they've ever made and will make in perpetuity that never brings back a life. So really it's

01:32:11.180 about two things, isn't it? It's sort of about how much can be fixed today with money, because maybe

01:32:18.480 some things can be fixed with money, some things can't. I guess three things is justice being served.

01:32:24.960 And the third thing would be, is this creating a deterrent for another entity in the future

01:32:31.820 to be a little more careful with what they do? Let's talk about the latter. Do you think that

01:32:38.400 this will create a sufficient enough deterrent? And not just this. I mean, if you look at,

01:32:42.480 what was that other company, Insys or something like that? Insys, yeah.

01:32:45.640 Yeah. Insys was different because Insys, people went to jail.

01:32:48.900 Yeah. So when you look at the totality of these things, do you think that at least for the foreseeable

01:32:54.620 future, the legal slash illicit drug market is on notice?

01:32:58.920 I do and I don't. Look, in some ways this fits into a larger trend that we've seen

01:33:03.380 happening over the last 10 or 15 years since the days of Enron and WorldCom, which is that there's

01:33:09.120 a pronounced disinclination, this is across political parties, to bring criminal charges and

01:33:17.040 jail time into the equation when it comes to corporate executives acting within their role,

01:33:24.700 even if the conduct is criminal. So you have this kind of bizarre thing with Purdue Pharma where

01:33:30.440 when the company pled guilty for a second time in 2020, there were no individual executives even

01:33:36.060 named. So as I say in the book, it's like it's a driverless car. How is it that the company could

01:33:41.300 commit federal crimes if there's no individuals who can be identified as having committed crimes? It

01:33:46.900 doesn't make any sense. But I think it's sort of expressive of or reflective of the general posture

01:33:53.020 of the Justice Department and our whole system of justice, broadly speaking, which is it's really

01:33:58.640 the exception when a corporate executive ends up doing jail time, as we saw in Insys. And the Insys

01:34:05.220 case is kind of particularly extreme. Insys is like everything you see in the Purdue story, but just

01:34:11.160 like dialed up to 11. I think there are a bunch of reasons why you saw jail time in the Insys case and

01:34:17.400 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

01:34:23.260 name. But yes, Insys was just such a scam. And there you have like strippers working as sales reps and

01:34:31.400 fairly sort of bald bribery schemes, not the soft corruption I've been talking about, but like the hardest of hard

01:34:37.540 corruption. So there you saw jail time. In my view, jail time is the only thing that really is a

01:34:44.060 deterrent. I think otherwise, I don't know. I mean, people are rational, particularly when it comes about

01:34:48.940 money. They think about risk. They evaluate risk. You know, you look at the Sacklers, right? It's like

01:34:53.480 you take $10 billion out of a company during a period of time when it's committing crimes. You're

01:34:59.120 going to have to give back $4.5 billion. Do you do it? You look at that fact pattern. You've got a

01:35:05.640 company. The company commits crimes. You own the company. You're on the board of the company.

01:35:09.440 You're never going to go to jail. You're never going to get charged with any crimes.

01:35:13.360 You will have to give back $4.5 billion, but you can do it over nine years. Do you do it? I could

01:35:18.320 probably go out on the street and find you some people who would say, hell yeah, sign me up.

01:35:24.960 For the Sacklers, I think, you know, the real costs are going to be reputational and it's hard to

01:35:29.720 measure that. You'd have to argue that are they any different from OJ Simpson?

01:35:35.640 You mean in terms of the notion that everybody knows?

01:35:38.740 Yeah. Like OJ Simpson commits this completely heinous, graphic, premeditated, violent act

01:35:48.880 in front of the world. And if not for a technicality, effectively an a racist cop gets off. But I don't

01:35:58.060 think the world's ever really forgiven him. My guess is he probably is being basically socially

01:36:05.240 punished for the rest of his life. And rightfully so. Is justice served? No, presumably not. He

01:36:11.640 should be in jail, but nevertheless. So the blood of two people is on OJ Simpson's hands. The blood

01:36:17.200 of how many people is on the Sacklers' hands? Conservatively. What would be the most conservative

01:36:21.880 estimate? Right? I mean, it's so hard to say, right? Do you look just at people who've OD'd on

01:36:27.880 OxyContin? And of course they would say, again, with that parsing, they would say, ah, yes, but

01:36:32.500 there were other drugs in their systems. Yeah. My point is of the half a million people who have

01:36:38.400 died in the last two decades, I'm willing to acknowledge that some subset, maybe a small

01:36:44.240 subset of those people, the blood is on the hands of this family. And work like yours has really

01:36:51.400 brought that to light. I just wonder what the rest of their lives look like. Will this be basically

01:36:56.500 forgotten about? Will the next generation of Sacklers carry no shame for this? Or will

01:37:02.240 this be something that forever makes people in polite company a bit embarrassed to be around

01:37:07.320 them? It's funny. I mean, I think both of the last two things you said are going to be

01:37:12.440 the case. I think people will forever be embarrassed to be around them. I think the name is toxic and

01:37:17.160 it's coming down off of institutions. I think it'll come down off of more institutions. I think that

01:37:22.260 the family isn't happy about that. But I also don't know that any of them feel any shame.

01:37:27.780 One of the things that's been so revealing to me, it's funny, there's an analogy that I don't draw

01:37:32.400 in the book in any explicit way, deliberately, but it was one that I thought about a lot is,

01:37:37.560 you know, I was writing this book in the last years of the Trump presidency. One sense in which

01:37:42.740 the Sackler situation, I think, was a little bit similar to Trump's, it's a sense in which I'm almost

01:37:47.240 sympathetic in both cases, is if you're a billionaire, you're surrounded by advisors and

01:37:53.280 lawyers and PR people and all these people whose livelihood depends on keeping you happy.

01:37:59.040 I feel as though that there is a kind of heightened danger of delusion of you just getting out of

01:38:06.800 touch with reality. And it probably starts in small ways. You tell a joke and everybody in the

01:38:12.420 room laughs. So initially, you're just like kind of a millimeter or two off track in terms of the

01:38:19.100 fidelity of your perceptions of the world. The longer you go, the further off course you get.

01:38:25.100 And what you saw with Trump, which you also see with the Sacklers, is that there are people in the

01:38:30.600 mix. I mean, I've talked to people who a decade ago said to the family, what if you took some of this

01:38:37.660 philanthropic money that you give to art museums and started a foundation dedicated to the study of

01:38:43.920 addiction, redressing the opioid crisis, people who were making, you know, frankly, a cynical argument,

01:38:49.920 but saying just purely in terms of the optics here, you should make some gesture, recognizing that

01:38:56.640 there's a problem and that people think that you're responsible for it. And those people were always

01:39:00.920 sidelined and fired. And the people who end up in the kind of inner circle are the ones who say,

01:39:06.720 you are just terribly misunderstood. All these people don't understand you. The press, the public,

01:39:13.120 the people making jokes on The Late Show, the attorneys general of every single state,

01:39:18.020 all these members of Congress who keep condemning you, all these studies that are done about OxyContin

01:39:22.440 and its legacy. It's all just a big misunderstanding. You never did anything wrong. And what's been

01:39:27.940 astonishing to me is they tend to pretty uniformly feel that way, the family members.

01:39:32.780 Yeah, that's one of the things that surprised me about your book is you had to do all of this without

01:39:38.100 actually talking to anyone in that family. And when you think about how many children the three

01:39:44.360 Sackler brothers had and how many children they had and how many spouses they have, that's a pretty

01:39:51.320 good list of people who could have come forth and said something to you even off the record or on

01:39:57.400 background. And yet I don't think that happened, did it?

01:39:59.700 Listen, my assumption from the beginning had been that there must be some apostate,

01:40:03.860 third generation Sackler who looks around and nevermind my writing, right? It's like they read

01:40:09.140 the New York Times, they read the LA Times, they read Sam Quinones' book, Dreamland, and they say,

01:40:15.300 Yeah, this is blood money. My trust fund is blood money.

01:40:17.840 I don't need this. I'm going to turn my back on it. Couldn't find one. One of the more revealing

01:40:23.060 documents, it's a WhatsApp log. It's like a chat log from the heirs of Mortimer Sackler. This came

01:40:29.880 out in the context of the bankruptcy proceeding, where they all talk over the course of a couple

01:40:35.020 of years, all these different family members, siblings, cousins, and they're talking about their

01:40:41.340 problems and how do you deal with it and the litigation and the bad PR and what's the right

01:40:45.920 strategy. And it's this private channel. And there's nobody, nobody who at any point says,

01:40:53.880 geez, maybe our critics have a point. Or like, maybe we should ask some tough questions. Instead,

01:40:59.440 it's this pretty lockstep feeling of persecution. And in fact, I mean, sometimes when you read their

01:41:05.540 private correspondence, the way they talk amongst themselves, at times it feels as though in their

01:41:09.640 minds, like the real victims of the opioid crisis are the Sackler family. That's amazing. That's more

01:41:16.260 amazing to me than the indignant response that is seen publicly. It's that even privately, there's no

01:41:24.120 awareness, not a shred of introspection. None. And a profound sense of grievance, a sense that they've

01:41:31.040 been kind of persecuted. I mean, there's this amazing email that I quote in the book where

01:41:35.600 Jacqueline Sackler married to Mortimer Jr., a second generation member who was on the board of

01:41:42.060 the company. She's talking about how with all this press coverage and the sort of stigma for the

01:41:46.260 family, she's worried about her children applying to elite private schools in Manhattan in the fall

01:41:52.760 and their chances. And in the context of griping about this, she says, children's lives are being

01:41:58.240 destroyed. Not to pivot from the comic to the tragic, but like I get emails every week from people who

01:42:04.620 lost children. When you hear from as many bereaved parents as I do, it's just amazing to read an email

01:42:10.960 like that and consider the level of disconnection that it betrays. I know you've spoken about how

01:42:17.720 you also hear from basically two groups of people, right? So you hear a lot from exactly what you've

01:42:23.440 just said, the family members or friends of people who themselves have become addicted or who more

01:42:28.000 tragically have lost those. But you also seem to hear from people saying your work is potentially

01:42:33.360 threatening to the supply of pain medication to people like me who genuinely and legitimately need

01:42:39.340 it, which of course is not your intention. But you seem to be sensitive to that and you seem to

01:42:44.140 understand that there's a fine line here, an overreaction or an overcorrection that would limit

01:42:50.440 the supply of or access of patients who do need pain medication to it would be an unintended consequence

01:42:57.060 of this work. So do you get a sense that that is actually happening?

01:43:00.340 Yes. I mean, I think that there is a definite sense in which the pendulum has swung back and in

01:43:09.620 which a lot of doctors are less likely to prescribe these drugs in the first place, more likely to

01:43:17.120 prescribe shorter courses at lower doses. I think a lot of that is a good thing. Ultimately, there are

01:43:22.980 many chronic pain patients. I certainly get emails from people talking about how they're fearful that their

01:43:29.040 supply of these drugs. I'm not just talking about OxyContin here, but prescription opioid painkillers

01:43:34.880 broadly that they count on in order to function in life is really jeopardized by these changing

01:43:41.200 currents in terms of the way in which people perceive these drugs. And it's an incredibly difficult

01:43:46.440 thing. I mean, I am very sympathetic to this. I certainly don't want to see people who use these

01:43:52.200 drugs stigmatized, whether they use them legally or illegally. I tend to be pretty sympathetic with

01:43:58.760 people. I'm also not a prohibitionist. You know, I don't, given all my work on illegal drugs, I tend

01:44:03.800 not to think that drug prohibition is the way to go. People certainly make arguments that if you cut off

01:44:09.020 pain patients, do rapid force taper and what have you, that that might actually drive people onto the

01:44:14.840 black market and become more unsafe, that that might be part of what's driving the opioid crisis.

01:44:20.660 Where I balk at that kind of, and this sort of goes back to the thing I said to you at the outset,

01:44:25.260 is the suggestion that I shouldn't write about the Sacklers and their culpability because there might be

01:44:30.160 some second or third order consequence of that, or that my focus is in the wrong place. I'm going to

01:44:36.760 write the books that I want to write and the articles that I want to write. I find it's very often the case

01:44:41.220 that people who are sort of telling me that I shouldn't be doing these things, generally speaking,

01:44:45.220 haven't read the book, haven't really engaged with the particulars all that much. But yeah, look,

01:44:49.300 I do hear from pain patients quite often. And I think this has been a sort of an agonizing period

01:44:54.880 for them because from where I sit, the problem was not that a drug like OxyContin shouldn't have been

01:45:01.120 produced or made available to pain patients. It was all in the decision to do two things. One was

01:45:07.720 dramatically expand the universe of people who should be taking it. And the other was,

01:45:12.220 I think, pretty systematically play down the risks so that there's a dishonesty with the consumer and

01:45:18.400 with physicians about what the dangers are. I don't go from that to any sense that these drugs

01:45:24.360 should not be available at all. There are some who do, some doctors who do. I sort of don't feel

01:45:28.740 the need to go there myself. I'm pretty squarely focused on the origins of the crisis and some pretty

01:45:33.220 unambiguous wrongs perpetrated by Purdue and the Sacklers. If the Sacklers represent a cancer,

01:45:38.920 that cancer has largely been excised. The Sacklers themselves are no longer going to be a part of

01:45:43.940 this dilemma. But unfortunately, the cancer metastasized before it was excised. So as you

01:45:49.460 point out, we still have an opioid crisis. And in fact, doesn't seem to be showing any signs of

01:45:54.700 abatement. In fact, last year, we saw more people die of opioid overdose than any other cause of

01:46:01.940 accidental death, which is actually a staggering statistic when you consider how many people

01:46:06.280 die in car accidents, how many people die of gunshot wounds. In that sense, your work has been

01:46:12.920 a success and the work of all the people you've written about who have finally brought a modicum

01:46:17.940 of justice to at least the initial perpetrators of this. But what does the path forward look like?

01:46:24.540 What will it take to actually address this crisis?

01:46:29.780 This will sound like a cop-out, but in some ways, I'm so overwhelmed by that question. I think anybody

01:46:35.520 would be. The way in which I've grappled with that is to kind of take this small piece of it that I can

01:46:42.380 focus on and understand. And for me, in some ways, it's kind of looking at the origin story of the

01:46:47.540 crisis, really more than where we are now. The numbers are staggering. As you say, they're getting

01:46:53.020 worse. The sense in which I feel as though the SACAs are not absolved by the fact that this is

01:46:57.280 today a heroin and fentanyl crisis is the sense in which there are many, many people who I think

01:47:02.520 would never have taken heroin or fentanyl in the first instance that started on prescription opioids

01:47:06.900 like OxyContin. But of course, from the vantage point of today, I'd rather people be abusing

01:47:11.760 OxyContin than abusing fentanyl or heroin that's laced with who knows what. It is a very, very scary

01:47:18.440 situation. I feel as though we need far more resources than we have. I mean, I think it's

01:47:24.620 a problem that needs to be resourced. I think treatment is very often not available to people.

01:47:29.080 I think there's still a huge amount of stigma associated with the abuse of an addiction when

01:47:34.440 it comes to these types of drugs. And anything we can do to diminish that stigma, I think medically

01:47:40.400 assisted treatment, which I think there are still some for whom that's a kind of a scary

01:47:45.580 concept. It's one that should be adopted and embraced and not cause the consternation that

01:47:51.240 it does for some. But I think it's a huge national crisis. And in a strange way, I feel as though

01:47:56.200 we're at not for COVID. It's not that the problem would have been solved. Just prior to COVID, there

01:48:01.480 was a sense in which I, you know, it's tricky because it was the Trump administration. But I

01:48:05.160 think there was sort of a recognition that we need a major national strategy to deal with this.

01:48:10.240 It is out of control and killing people in vast numbers. And we need to have all ideas on the

01:48:16.900 table and be strategic and resource the solution. And then COVID came along and there just wasn't

01:48:24.420 really the bandwidth or the oxygen in the room to have that conversation. But when we neglect the

01:48:29.760 problem as we have during COVID, purely in terms of the triage or the last 18 months, you see what

01:48:35.600 happens. Are you optimistic that 10 years from now, things will be different? I mean, I have to be

01:48:41.020 just because I'm, believe it or not, after this grim conversation, I'm fundamentally an optimist

01:48:45.360 about a lot of things. I have to believe we will learn and we'll sort of find a way out of this.

01:48:50.900 But it's hard. And I think the hardest thing in a way is I've had many of these conversations and

01:48:54.820 sound like you have too. You mentioned a patient who had a family member who actually managed to stop

01:49:00.280 using and seemed as though they'd moved on and then went to a party. Relapse is such an issue

01:49:06.400 with these drugs. When you talk to people who've sort of achieved, they've found their way out of

01:49:11.280 the woods. Often the thing that's so striking to me is that there's a sort of fragility to it.

01:49:17.500 They're always talking in the present tense. There's this sense that kind of every day

01:49:21.080 is a battle. And that's what worries me about the idea of us 10 years from now on a kind of very

01:49:26.940 micro level for the individual who is struggling with addiction. There's that sense in which it's

01:49:32.260 like each tentative step, you just never know when you're going to get pulled back in. And so on a kind

01:49:37.360 of macro level nationally, I worry that there may be a similar danger. Yeah. I worry about the impact of

01:49:44.860 what it takes to escape the gravitational pull of an environment that facilitated the use.

01:49:53.600 I did my residency at Hopkins, which is in inner city Baltimore. And even 20 years ago,

01:50:00.420 it was probably a leading indicator for how bad heroin use could get. We would take care of a lot

01:50:07.300 of patients who had abscesses and all sorts of infections and cellulitis and things like that from

01:50:14.260 IV drug use. Sometimes these infections themselves were life-threatening. So it wasn't just the overdose

01:50:20.580 on the drug. It was the repeated use of a dirty needle or a needle that gets broken inside the arm

01:50:26.700 and gets infected. And so you would take care of these patients and you always wish them the best

01:50:32.500 when they left. But in the back of your mind, you knew you were going to see them again, because

01:50:36.880 even though for the five days that they were in the hospital, they were not using any drug. And they,

01:50:43.400 with the total clarity of the thought that they had realized how lucky they were to get this second

01:50:48.960 chance, they were still going back into the same environment that brought them into the hospital

01:50:54.720 in the first place. And we used to say to ourselves, the only way this person's not coming back is if

01:51:00.940 they get a whole new group of friends. In fact, the best thing you could do for this person is get

01:51:05.260 them out of inner city Baltimore. They can't go back to the row home they came from. Now that might

01:51:10.960 sound like a very extreme example, right? Well, come on, inner city Baltimore. I mean, you're talking

01:51:15.180 about a crack house, but is it really any different for a college kid who's trying to

01:51:21.260 desperately get off the transition from oxycodone to fentanyl? And this is being done in a dorm room

01:51:28.940 or at a party or something like that. And it's their friends and they manage to pull out of the

01:51:33.720 grip of that, but they find themselves at another party in three months. I mean, it's really difficult.

01:51:38.420 That's the part that concerns me is it's hard to do this one person at a time.

01:51:42.140 Yeah. I come back to the, you know, that idea of undertow and even you telling your own story

01:51:47.460 about your experience with oxycontin. I think the big thing that comes home to me is just that

01:51:51.880 these substances are, they have an awesome power and that's compounded by all of the kind of

01:51:58.100 atmospheric, social, situational things you're talking about. But just having talked to a lot

01:52:03.300 of families over the years who've dealt with this and they thought they were out of the woods and then

01:52:08.220 they weren't, I think you're right in any one individual life. And even somebody who actually

01:52:13.020 has a really supportive, got a whole support system there. And in many instances, there are

01:52:17.940 people who they don't have the resources for the appropriate treatment, but in many instances,

01:52:22.280 there are people who do, who throw resources at the problem and it's not enough. It's not adequate.

01:52:28.540 I just think we should all be sort of humble and mindful in the face of the tremendous kind of

01:52:35.060 potency and power that's on the other side of this problem.

01:52:39.480 Patrick, thank you very much, first and foremost, for your book and your investigation, which I think

01:52:42.960 has brought to light a lot of things that probably could have easily gotten ignored or swept away. I

01:52:48.060 mean, it's true that during these proceedings, a lot of documents are brought into the public light,

01:52:52.960 but that's only half the battle. That's the easy half. The hard part is actually going through

01:52:56.620 them and extracting what the story is. And you've done a better job of that with respect to

01:53:00.740 this important part of the story than anybody else. But also thank you for making time.

01:53:04.580 I imagine as an author, you must get tired of having to do interviews on the same topic,

01:53:09.280 but I really appreciate it. Thank you, Patrick.

01:53:11.860 Really in-depth and yeah, I very much enjoyed it. It was a great conversation. Thank you.

01:53:16.860 Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper

01:53:21.040 into any topics we discuss, we've created a membership program that allows us to bring you

01:53:25.460 more in-depth exclusive content without relying on paid ads. It's our goal to ensure members get back

01:53:31.220 much more than the price of the subscription. Now to that end, membership benefits include

01:53:36.040 a bunch of things. One, totally kick-ass comprehensive podcast show notes that detail

01:53:40.920 every topic, paper, person, thing we discuss on each episode. The word on the street is nobody's

01:53:46.480 show notes rival these. Monthly AMA episodes or ask me anything episodes, hearing these episodes

01:53:52.180 completely. Access to our private podcast feed that allows you to hear everything without having to

01:53:58.240 listen to spiels like this. The Qualies, which are a super short podcast that we release every

01:54:03.620 Tuesday through Friday, highlighting the best questions, topics, and tactics discussed on

01:54:07.760 previous episodes of The Drive. This is a great way to catch up on previous episodes without having

01:54:13.100 to go back and necessarily listen to everyone. Steep discounts on products that I believe in,

01:54:18.740 but for which I'm not getting paid to endorse. And a whole bunch of other benefits that we continue

01:54:23.240 to trickle in as time goes on. If you want to learn more and access these member-only benefits,

01:54:27.940 you can head over to peteratiamd.com forward slash subscribe. You can find me on Twitter,

01:54:34.140 Instagram, and Facebook, all with the ID peteratiamd. You can also leave us a review on Apple

01:54:40.160 Podcasts or whatever podcast player you listen on. This podcast is for general informational purposes only

01:54:46.660 and does not constitute the practice of medicine, nursing, or other professional healthcare services,

01:54:51.340 including the giving of medical advice. No doctor patient relationship is formed. The use of this

01:54:57.620 information and the materials linked to this podcast is at the user's own risk. The content

01:55:03.280 on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or

01:55:09.060 treatment. Users should not disregard or delay in obtaining medical advice from any medical condition

01:55:15.800 they have, and they should seek the assistance of their healthcare professionals for any such

01:55:20.840 conditions. Finally, I take conflicts of interest very seriously. For all of my disclosures and the

01:55:26.480 companies I invest in or advise, please visit peteratiamd.com forward slash about where I keep an up-to-date

01:55:34.980 an active list of such companies.

01:56:04.980 Thank you.

01:56:05.980 Thank you.

The Peter Attia Drive - December 06, 2021

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

Episode Stats

Length

Words per Minute

Word Count

Sentence Count

Misogynist Sentences

Hate Speech Sentences

Summary

Transcript