Reading this book felt like living through all the maxims outlined by Robert Greene in his 48 Laws of Power. “Never outshine your master”, “Conceal your intentions”, “Play a sucker to catch the sucker”… and most importantly, “Play on people’s need to believe”. This book is about the secret history of the Sackler Dynasty, famous for building the “big pharma” empire.
More than anything, it was a dark and chilling depiction of how the “big pharma” operated. This was a term that was thrown around without much weight in newspaper columns, but I was able to finally breathe and vivaciously imagine what this is. It’s ultimately a story of the rich and the powerful and what money can buy. If there is something money cannot buy, through it’s tentacles, it finds workarounds to still buy it. The writer purposefully calls this as the ‘secret history’ because the Sackler dynasty is famously known to the outside world for it’s philanthropic ties (similar to the Medici in Florence), but they’re actually running the pharma show, and are the kingpins behind one of the most commercially profitable and morally bankrupt opioid by name OxyContin. The Sacklers are also the same folks behind Purdue Pharma which has now finally, pleaded guilty for corporate malfeasance, and have already paid hefty fines for all their negligence. More Americans have lost their lives due to opioid overdoses than an all wars the country had fought since World War II.
I read this book as I was so much in love with the style of Patrick Keefe’s writing, especially in this narrative non-fiction crime genre. I read London Falling last time as an audiobook, and I was gripped till the very end and couldn’t resist finishing it at one go. Another thing I liked about the style of writing, was the personal touch. At some point, the investigative journalist also becomes a part of the story line, interviewing the subjects and also adding his own personal take, after having lived and experienced the pain of his subjects in this book. It just showed how he was going above and beyond to really get to the meat of the story. So I expected something similar when I picked up Empire of Pain, and I was not disappointed.
Now, onto some ideas that I carried away from reading this:
Philosophy as a business transaction
Attaching a name to something, is an adult version of the kid with the largest number of toys. Philanthropy does that. Even if, on the surface it looks like you’re gifting something (money), and not getting anything out of that, you actually get a lot of perks which only money in the decoy of a philanthropic activity can buy. When Arthur Sackler gifted the Temple of Dendur to the Met museum, it was a convenient way for Arthur to attach the Sackler name to more objects. The writer describes this as a classic “Sackler play” — innovative, shady, charitable gesture, considering significant tax advantages, which would actually be helping him make more money..
I also learnt about the philanthropic concept of a dangle: As his relationship with the Met museum folks from Columbia were maturing, Arthur perfected the art of a dangle: where a wealthy patron can enjoy favours from a hard-up institution that’s far outside the reach of what anh gift could possibly provide:
Think of it as the dangle: a wealthy patron can often enjoy favor and influence with a hard-up institution that are far out of proportion to any gifts that have actually been made, because the canny donor learns to dangle the possibility of future gifts, and that is a possibility that the museum or university cannot afford to overlook. When the dangle is executed correctly, there is almost nothing that the institution will not do to keep the donor (or even the prospective donor) happy.
Bringing ads to a boring industry
The company went to puritanical measures to market their pharmaceutical products. Even though OxyContin (Oxycodone) was more lethal than morphine, they were able to market it as such because of oxycodone being less known to the market. They took advantage of this to a larger extent. Surprisingly even the doctors had a similar such misapprehension which was taken advantage of:
A century earlier, Bayer had marketed heroin as morphine without the unpleasant side effects, even though heroin was actually more powerful than morphine and every bit as addictive. Now, in internal discussions at Purdue headquarters in Norwalk, Richard and his colleagues entertained the notion of a similar marketing strategy. In truth, oxycodone wasn’t weaker than morphine, either. In fact it was roughly twice as potent. The marketing specialists at Purdue didn’t know why, exactly, doctors had this misapprehension about its being weaker
Oxycodone was a stigma-less word, and no one screamed out loud like in case of Morphine where you would find examples of “No! You can’t take morphine!”. OxyContin even has mantras such as “to start with, and to end with”, positioning themselves as an ultimate pain killer panacea. That it was good for acute short term pain, as well as for long term pain, as well as for any pain in general..
They even employed research as an obfuscation strategy. Their sales reps often referred to “medical literature” to combine the doctors on the usage of opioids, but at the same time the medical literature they quoted was heavily bastardised.
In urging doctors to write more OxyContin prescriptions, the sales reps often referred to medical literature, and to one study in particular. “In fact, a survey of more than 11,000 opioid-using patients, taken over several years, found only four cases of documented addiction,” they would say. The study had been published in the prestigious New England Journal of Medicine, they would explain, with a title that spoke for itself: “Addiction Rare in Patients Treated with Narcotics.” In truth, the item in the journal was not a peer-reviewed study at all, but a five-sentence letter to the editor by two doctors at Boston University Medical Center. The research it described was anything but comprehensive: it was based on a group of patients who were monitored on a short-term basis during brief stays in a hospital setting. Much later, one of the authors of the letter, Hershel Jick, would say that he was “amazed” by the degree to which Purdue and other companies used this minor academic offering to justify the mass marketing of strong opioids. The industry had co-opted his work, he suggested, using it “as an ad.” But for the reps, the study was irresistible, because it conveyed such a useful message: opioids might be associated in the public mind with addiction, but really it was exceedingly rare for a patient to become hooked on narcotic painkillers, so long as the drugs were being administered in a doctor’s care. And Purdue created the impression that this new perception of opioids was an increasingly mainstream view. The sales team had what the company described as “non-branded” literature: material generated by ostensibly independent groups, which had actually been produced or funded by Purdue. The company established a speakers bureau, through which it paid several thousand doctors to attend medical conferences and deliver presentations about the merits of strong opioids. Doctors were offered all-expenses-paid trips to “pain management seminars” in places like Scottsdale, Arizona, and Boca Raton, Florida. In the initial five years after OxyContin’s release, the company sponsored seven thousand of these seminars. The marketing of OxyContin relied on an empirical circularity: the company convinced doctors of the drug’s safety with literature that had been produced by doctors who were paid, or funded, by the company.
Not just research being misused and done under unethical and unfair environments, they also leveraged health conferences. On the surface, these looked like any other medical conference: you had the doctors talking about doctor things with other doctors, but under the surface, there was a hidden agenda: to make it implied that morphine is the best and safest treatment for chronic severe pain. This strategy was extended to other drugs too..
Economics of drug to market play
As soon as a Pharma company has come up with an innovative drug, the clock starts clicking until the time the patent exclusivity expires. There is only a limited time period wherein the branded drug maker can reap outsized profits. The drug maker is always selling on borrowed time ending in a disappointing fashion, what the makers call as the “patient cliff”
Even when a drug is tremendously lucrative—in fact, especially when a drug is tremendously lucrative—the drugmaker is always selling on borrowed time, conscious that at some fixed point in the future the patent will expire and the generics will come rushing in to decimate profits. There’s a phrase used in the pharmaceutical business to describe this inevitable but terrifying stage in the process. They call it “the patent cliff,” because that’s what a graph of revenue resembles at the moment when the patent expires: a drop so steep it’s like plummeting off a cliff.
