June 2021

Favorites of the month: Empire of Pain: The Secret History of the Sackler Dynasty and Klara and the Sun

In the 1950s and 60s, the United States was steeped in an “Age of Anxiety” not too dissimilar from our own. The “cold” conflict with the Soviets had come to a boil, with nuclear war seeming imminent and assassinations of public figures becoming increasingly commonplace. Around this time, at the Roche laboratory in Nutley, New Jersey, a chemist named Leo Sternbach worked to concoct two “minor tranquilizers” – Librium, a portmanteau of “equilibrium” and “liberation”; and Valium, a play on the Latin word “valere,” meaning “to be in good health.” With the ability to mollify patients without making them groggy or infirm, the two drugs were hailed as “miracle pills,” both tailor-made for a colossal (and still largely untapped) market. Even so, Roche struggled with how to sell them: How could the company offer two pharmaceuticals “for the masses” given the stigma still attached to mental illness? And how could it sell such two similar products without effectively shooting itself in the foot? The answer to these conundrums, ultimately, came via Arthur Sackler, a physician and pharmaceutical ad man, who devised a strategy of marketing Librium and Valium as two indispensable – but critically different – palliatives for twentieth century living. Over the next few years, his scheme would reach thousands of people affected by an outrageous range of conditions, positioning him as the patriarch of one of the wealthiest and most notorious families in the country.  

In his extraordinary book, Empire of Pain, Patrick Radden Keefe exposes the hidden history of the Sacklers, the family responsible for making and marketing Oxycontin. It begins in the summer of 1913 with the birth of Arthur Sackler, the firstborn son of Polish and Austrian immigrants, struggling to make ends meet in turn-of-the-century Brooklyn. From an early age, Arthur was inexhaustibly energetic, curious, and ambitious. Attending Erasmus High School, with dreams of one day becoming a physician, he seemed to thrive on power and praise – “as if he had found a way to metabolize other people’s admiration.” By the time he was twenty-four, he had received his undergraduate and medical degrees from NYU and begun his residency at the Creedmoor Psychiatry Institute, paving the way for his two younger brothers – the high-flying and “hot-tempered” Mortimer and the more “even-keeled” Raymond – to follow in his footsteps. Keefe tells us that at Creedmoor, Arthur was disgusted by the way patients were treated. Witnessing lobotomies and electroshock therapy, he became convinced that mental illness was not just experiential but biochemical. What if there was a treatment, he wondered, that could help people without leaving them permanently traumatized or debilitated.

It is this question that got Arthur into medical advertising – specifically the advertising of Librium and Valium. In marketing the two “wonder drugs,” he combined the hallmarks of conventional advertising (i.e., compelling slogans, visually engaging graphics, etc.) with a direct appeal to prescribers as he invested in advertisements, mailings, and direct physician engagement. As a doctor himself, Arthur trusted physicians implicitly, regarding them as an “unimpeachable” audience. As a marketer, he also understood – and actively capitalized on the fact – that most Americans did too. Across the country, doctors were perceived as noble and incontrovertibly oath-bound; they’d never steer their patients wrong or give them a drug they couldn’t handle. Besides, Arthur believed, “it’s not the drugs that are bad; it’s the people who abuse them.”

From there, Arthur became like a larger-than-life octopus, digging his tentacles into almost every aspect of medicine as if it were an ever-compounding goldmine. In just a few years, he became the editor of a medical journal, established a medical publishing company, launched a radio service and a weekly newspaper for physicians, and purchased a pharmaceutical company – Purdue Frederick – for his brothers Mortimer and Raymond. As Arthur amassed obscene amounts of wealth, he became manically acquisitive, particularly in the domains of art and philanthropy, which he considered a form of “family branding.” He also became more and more “slippery.” His seemingly “altruistic acts” were almost always performative while his relationships and transactions were invariably “cloaked in secrecy.” With each passing year, he became increasingly addicted to the reputational perks of philanthropic giving without ever really having to give. At the same time, he became addicted to the privileges of wealth without ever really having to explain how he was spending it (or even how he got it in the first place).

With Arthur’s death in 1987, the Sackler family forked, morphing from a powerful but contained triumvirate into a fractious, smug, and intractable dynasty. As Keefe shifts his focus from the three Sackler brothers to their children and grandchildren, he exposes a family tainted by an inherent “lack of empathy.” Showing “no trace of [their] humble origins,” he writes, the second and third generations of Sacklers viewed “life as a playground” and wealth as absolutely paramount. At the helm of these younger generations was Richard, son of Raymond, who as former chairman and president of Purdue Frederick oversaw the company’s transition from “a sleepy manufacturer of laxatives and earwax remover” into a pain management juggernaut. Just as Arthur had helped Roche market Valium and Librium as chemical prerequisites for modern life, Richard viewed pain as “the most common symptom that patients have.” Under his leadership in 1984, Purdue Frederick released MS Contin – a “more approachable” delivery mechanism for morphine; and in 1996, the company, now renamed Purdue Pharma, introduced Oxycontin. Heralded as a groundbreaking treatment for chronic pain, Oxycontin contained oxycodone, a chemical variant of morphine and heroin. Extremely potent and highly addictive, oxycodone had previously only ever been available through low-dose therapeutics like Percodan and Percocet. But under Richard’s leadership, Purdue Pharma argued that they could administer larger doses – and conveniently side-step any risk of addiction – by applying a patented coating, by which “more formidable” quantities of oxycodone could be filtered into the blood stream over an extended period of time. By taking Oxycontin, they maintained, patients would be protected from the instantaneous rush afforded by heroin and, as a result, would not be “whipsawed” between periods of intense high and wrenching withdrawal. The problem with this supposition, of course, was that no part of it was ever experimentally proven.

Evidence notwithstanding, the Sacklers set out to emulate Arthur’s strategy with Librium and Valium, aggressively marketing Oxycontin as not just “a drug for everyone,” but “the drug to start with and stay with.” In an effort to get physicians and patients better “acquainted” with Oxycontin, they established a discount program, by which new patients could receive a free thirty-day prescription. They also instructed sales reps to target physicians who were “opioid naïve.” Before long, the drug had become one of the biggest blockbusters in pharmaceutical history, to the point that the company couldn’t make it fast enough to sell it.

As much as they tried to convince themselves otherwise, however, the Sacklers had not been able to dissociate the dangers of addiction from “the medical powers of the poppy.” Because oxycodone is highly addictive, patients found that they needed more of the drug at more frequent intervals in order to avoid withdrawal. Sick and desperate, these patients had no other choice but to resort to “doctor shopping,” stockpiling prescriptions, sharing pills with friends, and altering the drug’s physical properties to accelerate and magnify its impact. By the time Purdue Pharma finally reformulated Oxycontin in 2010, it was too late. Across the U.S., patients had moved on from Oxycontin to more powerful and accessible substitutes like heroin and fentanyl, precipitating a full-blown opioid epidemic.

Just as Arthur had believed that “it’s not the drugs that are bad,” so too did the younger generations of Sacklers maintain that the “rare” cases of abuse stemmed not from the addictive properties of the drug but rather “the addictive personalities of the users.” “Addicts want to be addicted,” Richard insisted. To Richard and the other Sacklers, the real victim of the opioid crisis were not the people struggling with addiction, but rather Purdue Pharma itself. Amid a deluge of social expatriation, lawsuits, and “biased” media attention, the company leaders assumed “a bunker mentality,” surrounding themselves with sycophants while conceding “absolutely nothing” – even as the crisis they caused killed 50,000 people every year.

Keefe’s Empire of Pain is so well-written that it often reads like a movie in the vein of Spotlight or Erin Brockovich. Complete with brilliant descriptions of lavish New York galas, beachside “investment properties,” luxury resorts, overflowing art collections, and Machiavellian courtroom tactics, it tells the story of not just the opioid epidemic, but the family who refuses – even now – to take accountability for it. In doing so, it forces us to examine the fine line which exists between innovation and greed, as well as that which exists between ownership and culpability: Does the maker of an abusable product bear any responsibility when that product is abused? And should Arthur Sackler, the architect of Purdue Pharma’s advertising model, be held accountable for what his model did, even decades after his death?

Last December, members of the House Oversight Committee questioned several members of the Sackler family at a congressional hearing examining their role in the opioid epidemic. Throughout the hearing, Keefe writes, the family seemed “comically out of touch” as they put on a performance marked by feigned sympathy and shameless self-victimization. At one point, Representative Jim Cooper (D-TN) called this performance out: “I think Upton Sinclair once wrote that a man has difficulty understanding something if his salary depends on his not understanding.” “Watching you testify,” Cooper continued, “makes my blood boil. I’m not sure that I’m aware of any family in America that’s more evil than yours.” 

Cheers to Patrick Radden Keefe for transfiguring Cooper’s piercing words into such an exhaustive and uncompromising investigation. His is a book you will certainly not want to miss.

Kazuo Ishiguro’s latest novel, Klara and the Sun, begins in a nondescript store on a nondescript street, where Klara, a solar-powered Artificial Friend or “AF,” is waiting to be taken home. “Her ability to absorb and blend everything she sees around her is quite amazing,” the store manager says to a customer as she emphasizes Klara’s insatiable “appetite for observing and learning.” Klara, indeed, is intensely perceptive: Making constant recalibrations and “adjustments,” she is able to discern many (but not all) of the nuances and gradations of human emotion, such as a child’s fear of loneliness or a mother’s “angry exhaustion.” Once she is selected by a “friend,” Josie, and enters the outside world, Klara’s observations become even more complex as Josie vacillates between loving and automatizing her – between treating her like a best friend and a servant to control and “command.” With immediate and uncomplicated processing, Klara regurgitates these observations back to the reader, creating a picture of a world where humans rely solely on “rationality”; where technology is the catholicon for any predicament or loss; and where nothing – not even the sanctity of the human soul – is safeguarded from impermanence or replacement.

In her review for The New York Times, Radhika Jones draws a connective thread between Klara and Ishiguro’s earlier novels, underscoring the singular way in which he lends a voice to “not the human, but the clone; not the lord, but the servant.” Certainly, Klara and Stevens, the protagonist of Ishiguro’s Remains of the Day, share many similarities. They both exist as dependent and imitative shadows, unable to reckon with the indignity of their own self-denial; and they are both stubbornly optimistic, insisting on their masters’ good intentions, even when all evidence points to the contrary. Yet unlike with Stevens, Ishiguro is frustratingly ambivalent about Klara’s humanity. There are times in which Klara seems to feel excited, fearful, hopeful, sad, or regretful – “I believe I have many feelings,” she says to Josie’s mother at one point. That being said, Klara is unable to digest the full range of human emotion, nor can she comprehend how people are able to feel multiple emotions at once – that is, until she observes it or until someone explains it to her. Viewing emotion as a finite and “reachable” empiricism, Klara thus doesn’t feel as much as she observes, computes, and mimics. “The more I observe,” she explains, “the more feelings become available to me.”

As in Remains, Ishiguro writes with a steely, mechanical prose that seems tailor-made to reflect the lifelessness of Klara’s world. What results is stylistically impressive (and even moving), though not necessarily enjoyable to read. Like its titular robot, so much of Ishiguro’s Klara feels disconnected, haphazard, and annoyingly implicit. We know in Klara’s world, for example, that there has been some sort of shift, separating the modern present from an overly sentimental and misguided past. However, we never know why this shift happened or how people came to abandon their so-called “old feelings.” Such a “read between the lines” approach may work in Remains, where the characters, setting, and plot line mirror our own reality. But in the semi-dystopian Klara, too much is left unsaid.

The book jacket of Klara synopsizes it as a novel about “the wondrous, mysterious nature of the human heart.” But it’s really not. Whether human or robotic, the novel’s characters are all too hollow and indecisive to reveal anything much about the human heart, perhaps apart from its mercuriality. Klara is therefore not so much a story about the heart as it is a cautionary tale against losing it. To be sure, the world of Klara is not one any reader will want to occupy for long. Its final page comes not with a smile, but a sigh of relief – a hopeful reassurance that we are still human; that we can still feel; and that it’s not too late.