48 PROFITS AND CORPSES

The strict terms of the Consent Agreement signed by the Sackler-family directors should have been the end of OxyContin’s nationwide trail of destruction. The worst was yet to come, however. What seemed like a persistent problem in 2007 would over the coming decade develop into a full-blown national epidemic, a public health crisis that has claimed several hundred thousand American lives. The most lethal years and the greatest abuse would all come after the 2007 guilty plea.

Purdue apparently decided to break most of its promises to the federal government. The company did not report dangerous prescribers. It did not even order that the detail team stop visiting them.1 Instead, it expanded OxyContin’s deceitful promotion and sales campaign for the sole purpose of selling ever-more drugs for the longest possible period and at the highest dosages.

A few months before the plea agreement, the Sackler-family directors received a report that forecast a 2007 profit of $407 million. At a July 15 board meeting, just two months after their legal settlement, they learned that estimate was too low by 50 percent. Net sales in 2007 would top a billion dollars and produce profits of more than $600 million.2 OxyContin was responsible for ninety percent of all revenue.

The main reason for the huge spike in the bottom line? “Sales effort,” according to internal memos. At the time, Purdue had 301 sales representatives (compared to 34 in drug research). The detail team’s focus on getting physicians to write higher-strength prescriptions had paid off. More than half of the 2007 record-setting revenue was from sales of the 80 mg pill, at the time the most powerful OxyContin.3 Over the coming decade, Purdue more than doubled the size of its detail team, hiring hundreds of new reps to keep up with the drug’s surging demand.4

The Sackler-family directors were not remote board members with little idea of what was happening inside the company. Internal documents reveal the extent to which many Purdue executives and managers who reported to them complained about their micromanagement, particularly from Richard Sackler. Once he overruled a recommendation from one of the company’s outside counsel that it keep a wide distance from the three executives who had pled guilty. Why? he asked. They had made a public statement of contrition and paid large personal fines.5 Although Goldenheim had left the company, Friedman visited regularly and Howard Udell had moved back into his corner office and helped sometimes with in-house legal matters. Also, after their guilty plea, the Department of Health and Human Services had banned the trio for twenty years from doing business with any taxpayer-subsidized health care (Medicare, Medicaid, etc.). Richard Sackler had spearheaded the effort to hire a premier law firm that appealed that ruling and got the ban reduced to twelve years. (Their effort to get it lifted entirely was rejected in 2010 by a Washington, D.C., judge.)6

The Sacklers approved several million dollars in payments to the convicted executives (the largest was $3 million to Michael Friedman).7 That money helped offset most of the impact from the fines that had been levied against them. The Massachusetts attorney general later charged that the help to the three men was “to maintain their [the three executives] loyalty and protect the Sackler family.”8

The author uncovered that, in the wake of the bad publicity from the criminal guilty plea, Purdue relied increasingly on influencing the “key physician opinion leaders” as it tried to maintain the momentum of Oxy’s sales. An example was Advances in Pain Management, launched near the time of the plea agreement. It was jointly sponsored by the University of Kentucky Colleges of Pharmacy and Medicine and Remedica Medical Education and Publishing. Purdue had flooded Kentucky medical and pharmaceutical school curriculums with grants and subsidies. The Kentucky Pharmacists Association had opposed stricter dispensing rules for OxyContin in 2001.9 Remedica was a London-based medical publisher that had been founded the same year Purdue released OxyContin.10

It might seem unlikely that a London publisher ended up as a partner with an accredited college of pharmacy located in a ground zero state for OxyContin abuse and diversion.11 Who were its editors? Russell Portenoy, a leading voice for the pain and opioid reevaluation movement, was the journal’s editor-in-chief. In a small-print footnote in the first issue, Portenoy listed forty-two “relevant financial relationships” with pharmaceutical companies, including Purdue.12 The associate editor was Ricardo Cruciani, an Ivy League–trained chair of the neurology department at Philadelphia’s Drexel research university. Portenoy and Cruciani reversed positions on the masthead in late 2008. One of the journal’s featured writers was Lynn Webster, a Utah-based anesthesiologist who was an advocate of pseudoaddiction and had created the Opioid Risk Tool, a bare-bones five-question assessment intended to ferret out patients at risk of abusing opioids.13 For doctors not up-to-date on the latest developments in pain management, that one-minute screening contributed to a false sense that liberalized dispensing of opioids was not risky. Purdue, and other opioid manufacturers, featured it on their websites.14 The CDC ultimately concluded that Webster’s screening test was ineffective; it had “insufficient accuracy” and was “extremely inconsistent.”15

Was it a coincidence that Advances in Pain Management published articles that at times seemed as if they were taken from Purdue’s marketing playbook?16 Portenoy and Cruciani received more than $2 million over time for consulting, lectures, and research from Purdue and other opioid manufacturers.17 Lynn Webster’s Lifetree Pain Clinic in Salt Lake City had also received millions in research; an investigation by The Salt Lake Tribune later reported that Webster ranked “among the top 50 for single largest payments received” from drug companies, “behind marquee hospitals, such as the Mayo Clinic, Cleveland Clinic and Duke and Harvard Universities.”18 Portenoy and Cruciani were not far behind as recipients of drug company largesse (the money spigot to Cruciani was cut off in late 2017 after seventeen of his female patients in three states accused him of sexual assault and rape; he was convicted the following year and is serving a ten-year sentence).19

Webster’s Lifetree Pain Clinic closed after the DEA raided it in 2010 and discovered a file cabinet labeled “deceased patients.” More than twenty of his patients who were prescribed massive doses of OxyContin had died under his care. (The U.S. attorney did not file criminal charges, something a DEA agent described as the “most frustrating event of his career.”)20 Webster’s problems did not mean that Purdue distanced itself from him. It continued paying hundreds of thousands to Webster as he continued echoing the party line for liberalized opioid dispensing. With Purdue’s backing, Webster later became the president of the American Academy of Pain Medicine and a senior editor of Pain Medicine, a journal that relied only on advertising from Purdue and other drug companies with narcotic painkillers.21

Working with key physicians in the reevaluation movement and lobbying for good coverage in pain specialty periodicals was just one strategy that Purdue rolled out to prevent OxyContin’s sales from plateauing after its 2007 federal guilty plea. The following year, it added over one hundred new sales representatives and introduced an opioid savings card that discounted the first five prescriptions (induced by those discounts, 160,000 people tried OxyContin for the first time and 44,000 became repeat patients). The marketing and promotion budget doubled to $160 million.

Still, the Sacklers worried about more than simply a slowing of Oxy’s momentum. Purdue was a one-drug company whose future success lay in selling as much OxyContin as possible for as long as possible. Richard sent a private memo to his relatives on the board in mid-2008 and warned about “a dangerous concentration of risk.” He raised the possibility that they might want to sell Purdue; OxyContin’s success meant they could get a great price. That idea fell flat with other family-directors who instead wanted to “milk the profits.”22

At four board meetings in 2008, the Sackler directors voted to distribute $850 million to themselves from Oxy’s record profits.23 According to “some people close to the family,” the Wall Street Journal later reported, how much and when to take profits was a matter on which the directors did not always agree. The unidentified sources told the Journal that Raymond Sackler and his relatives—Richard, Jonathan, and David—wanted to reinvest the profits into the business while Mortimer and his relatives—particularly Kathe and Mortimer D.—insisted the money be paid to the family.24 At the September 2008 board meeting, the Sackler directors voted themselves $199 million in profits. At the following month’s meeting they got a report that acknowledged OxyContin abuse and diversion was a nationwide problem. One hundred and sixty-three tips about excessive prescribing and diversion had come into Purdue’s hotline the previous month. None were reported to law enforcement or the FDA. With that unpleasant discussion over, the Sacklers focused on a new “Toppers Club Sales Contest.” The five sales representatives who managed the biggest increases in revenues in their territories stood to win the largest bonuses ever paid by the company.25

The competition resulted in another year of record revenues. That translated into huge bonuses more than double the expected quotas for the entire sales force. At the same March 2009 board meeting at which the Sacklers approved the Toppers Club Sales Contest, they voted another $200 million for themselves.26 Two months later they were informed that the company had violated the Corporate Integrity Agreement that had been part of their 2007 guilty plea. Purdue’s managers had ignored their obligations to oversee the detail team and prevent misrepresentations in the pitches to doctors. The Sacklers’ response? They fired three salesmen. They also approved another $162 million in payments to themselves.27 A couple of months later they voted to pay the family $173 million despite a flurry of internal correspondence showing that both Richard and Mortimer were concerned about a sales department prediction that OxyContin’s revenue was flattening and might soon decline. To reinvigorate sales, in 2010 Purdue introduced a “new and improved” tamper-resistant OxyContin. David Sackler later claimed the two-year project cost the company $1 billion. Purdue touted the new version as more difficult to crush, snort, or inject. The company knew its reformulated version helped in only a small minority of instances in which someone did that to get an immediate high.28 Upward of 90 percent of patients misused OxyContin by swallowing the pills.29

The company had conducted two small trials, run by three employees and a paid consultant. In one, recreational drug users thought the tamper-resistant coating made Oxy less desirable. In a second study, twenty-nine subjects, for seven days, snorted crushed tamper-resistant Oxy while others got a placebo. Purdue concluded from the ratings given by the volunteers that the tamper-resistant version had “a reduced abuse potential compared to the original formulation.”30

From years of accumulating data, the FDA knew the two Purdue studies proved little. The agency’s officials informed the company that during its field tests of the new version, there was “no effect” in reducing the addiction and overdose potential. Still, the FDA approved the tamper-resistant OxyContin.

The author learned the reason Purdue wanted the new coating was not about reducing the deadly fallout from its star drug, but to obtain a patent extension to prevent generic competition. Once the FDA approved it, Purdue rolled out a campaign titled Opioids with Abuse Deterrent Properties.31 It spent millions on sponsoring and touting its crush-resistant formulation as the first ever narcotic pain reliever that reduced the chances for abuse and slashed the addiction rate.32

The campaign worked. Many doctors believed it and picked up their prescribing pace. That physicians were susceptible to pseudoscience, of course, was something Mortimer and Raymond had learned decades earlier from Arthur and his major drug launches at the McAdams agency.

In 2010, Purdue spent a record $226 million on marketing and promotion, mostly for its “new and improved” OxyContin. Some of the marketing budget was for the release of a new FDA-approved drug Purdue had worked on for nearly three years. Butrans was a narcotic patch the company claimed delivered a five-day dose of buprenorphine, a synthetic opioid twenty-five to forty times more powerful than morphine. Although its clinical tests demonstrated it was ineffective in treating osteoarthritis, at a board meeting the Sacklers asked if it was possible for the sales reps to omit that failed study. The detail team later mentioned osteoarthritis in over a third of their doctor visits without citing the negative trial results.33

The Sacklers pushed the sales team to its limits. Each rep had to meet escalating target quotas for how often they visited physicians. The average was 7.5 visits daily. In 2010, that translated into more than half a million one-on-one sales pitches. Starting the following year, with yet a larger detail squad, the number of visits hit three quarters of a million.34 Dozens of internal emails and memos reveal that the Sackler-family directors believed the sales team could always do more as well as do it better.35

The one matter on which there were no complaints from the Sacklers was how much money they got from Oxy profits. At four board meetings during 2010, they approved an additional $890 million for themselves ($249 million in February, $141 million in April, $240 million in September, and $260 million in December).36 They also ratified a remarkably ambitious ten-year plan that included doubling the detail team and increasing opioid sales by 20 percent annually. It projected that the profits to the Sackler family from 2010 through 2020 would be “at least $700,000,000 each year.”37

In 2011, four years after the criminal guilty plea by Purdue and three top executives, OxyContin gained the dubious distinction as the country’s most deadly drug, surpassing the combined fatalities from heroin and cocaine overdoses.38 The Sacklers worried about the increasing media coverage that blamed the company for how aggressively it fed the demand and ignored the “danger to public safety.” The family believed it encouraged more legal complaints against Purdue. A few months earlier they had approved $22 million to settle several dozen private lawsuits. While those civil suits were a nuisance, what was more worrying to the Sacklers was renewed interest from law enforcement. Purdue had managed to keep the FDA at bay during its 2007 criminal plea for misbranding Oxy. It might not be so fortunate the next time.

Purdue’s compliance department had informed the Sacklers that the number of complaints about abuse or diversion to the company’s hotline had broken a record in the last quarter of 2010. Purdue again did not report to the FDA any instances in which the sales representatives might have underplayed OxyContin’s addictive power in their pitches to doctors.39 Later, when one of the key elements in the lawsuits brought by dozens of state attorneys general was Purdue’s overzealous marketing of OxyContin, the company’s legal defense was to shift the responsibility for the drug being dispensed and abused so widely to the doctors who wrote the prescriptions.40

The Sacklers turned to legal matters in their first board meeting in January 2011. They authorized Purdue to pay all legal costs for an extended group of Purdue executives and sales managers. The Sacklers wanted to send a signal to employees that the family “had their backs.”

It had been John Crowley, the company’s executive director of Controlled Substances Act compliance, who had brought to the board’s attention that some key producers on the detail team worried about the consequences of getting dragged into legal contests, even if only as witnesses or for depositions. Legal fees could be devastating. Crowley was concerned for good reason. A sales manager, Michele Ringler, had emailed him in 2009 about her suspicions that a Los Angeles pill mill was ordering an inordinate amount of OxyContin from distributors. Lake Medical was a two-room “pain clinic” that an ex-felon and his physician partner had opened the previous year. Most pharmacies in Ringler’s L.A. sales territory ordered an average of 1,500 OxyContin pills monthly. Lake Medical averaged that every week.41 “I feel very certain this is an organized drug ring,” Ringler told Crowley. “Shouldn’t the DEA be contacted about this?”

Crowley did nothing. Ringler’s suspicions were right. By the time the DEA closed down Lake Medical in another year, it had distributed more than a million OxyContin pills to the Crips gang and Armenian traffickers. Only after the clinic was shuttered and its owners indicted did Crowley tell the DEA what Purdue knew.42

“They had an obligation, a legal one and a moral one,” said Joseph Rannazzisi, the DEA agent who had replaced Laura Nagel in 2005 as chief of the agency’s Office of Diversion Control, responsible for oversight of the pharmaceutical industry.43 Inside Purdue, detail team managers mocked the idea they should be bound by some ill-defined and nebulous concept of moral obligations. Apparently, the Sackler-family directors thought it was foolish to expect moral parameters to limit acceptable industry business practices. In the cutthroat world of pharmaceutical sales, any company that enforced “moral obligations” would be pulverized by competitors. The only rules to follow were those few on which they had no discretion. That was not as simple a maxim as it appeared. Virtually every rule that appeared ironclad was subject to legal interpretation. The DEA’s Rannazzisi had both law and pharmacy degrees; he construed the Controlled Substances Act to require pharma companies and drug distributors to reject and report “suspicious orders” if they had reason to believe the drugs might be illegally diverted.44 Purdue’s general counsel, Phil Strassburger, gave legal cover to Crowley and others in the compliance department. “It would be irresponsible to direct every single anecdotal and often unconfirmed claim of potential misprescribing to these organizations,” contended Strassburger.45

While Rannazzisi had expected to get stonewalled by Purdue or Johnson & Johnson, he had hoped he might get some voluntary compliance from the distributors, the big companies in between the pharma firms and the pharmacies, hospitals, and doctors’ clinics. “Cardinal Health, McKesson, and AmerisourceBergen,” he said, “control probably 85 or 90 percent of the drugs going downstream.” The distributors maintained precise data for how many pills go to each pharmacist for whom they fulfilled orders. Rannazzisi knew there were instances in which the distributors had ignored warning signs that were impossible to miss unless they did so intentionally. There was one pharmacy, for instance, in Kermit, West Virginia, a town of 392 people. It ordered over nine million OxyContin in two years. Neither Purdue nor the distributors filed any timely report to authorities about that pill mill.46 “There were just too many bad practitioners, too many bad pharmacies, and too many bad wholesalers and distributors,” concluded Rannazzisi.I47

The legal headaches were the inevitable costs, contended the Sacklers, of being the market leader on a drug that was a controlled substance. What about the fallout from Vioxx a few years earlier? they asked rhetorically. FDA officials had estimated that Merck’s nonnarcotic painkiller had killed sixty thousand Americans, more than had died during the Vietnam War.48 Independent statisticians contended Vioxx might have been responsible for half a million deaths by increasing the risks for a lethal heart attack for those patients who were genetically susceptible.49 Vioxx had indeed caused a national uproar. It tarnished Merck’s sterling reputation. It led to calls to invest the FDA with authority to review the safety of medications it had previously approved. Thousands of lawsuits were filed; Merck settled them in 2007 for $4.85 billion, then a record for pharmaceutical litigation.50

The insulated “circle the wagons” mentality was reinforced by every media story that portrayed Purdue as the villainous face of the opioid industry. There was also a perception, the author has learned, among the Sacklers and top management that plaintiffs’ lawyers and government investigators had focused on Purdue because it was the only privately owned company then selling a successful opioid painkiller. Its competitors were well-known publicly traded firms selling everything from extended release pills mixing opioids and anesthetics to fentanyl patches (among others, Johnson & Johnson had Nucynta, Pfizer made Embeda, Janssen Pharma had Duragesic, Cephalon/Teva had Actiq, and Bio Delivery Sciences had Onsolis). The opioid painkillers sold by large publicly traded companies were a small part of their diversified product lines. While those painkillers were profitable, the companies did not depend on them. Without OxyContin, Purdue would close shop. That made it simpler in a court of public opinion to portray Purdue as nothing more than a legally sanctioned drug dealer.

The DEA’s Joseph Rannazzisi was an eyewitness to better treatment that some enormous public corporations got as compared to small companies. McKesson, AmerisourceBergen, and Cardinal Health were all Fortune 500 companies (ranked 6, 12, and 15, respectively). They had pushed back against Rannazzisi’s aggressive enforcement for hundreds of instances where they failed to report and reject “suspicious orders.” Rannazzisi’s Justice Department superiors grilled him about his tactics against the distributors. That had “infuriated” Rannazzisi, who refused to change his attitude that “this is war. We’re going after these people and we are not going to stop.” The distributors, according to Rannazzisi, lobbied to get the DEA to change course. And it did. It stopped using its strongest remedy, the ability to freeze distributors’ shipments of drugs, against any of the largest companies.

“So the question is,” asked Rannazzisi, “why would it be any different for these companies as compared to the small mom-and-pops that we had done hundreds of times before? The difference is, they have a lot of money, and a lot of influence.”51

“With a privately run company, the owners become the face of the business,” a lawyer friendly with the Sacklers told the author. “What do you think worried the Sacklers? What do you think juries in Appalachia might think if they got the idea that a family of New York Jews made a fortune from a drug that some lawyer tells them was to blame for all the misery in their communities?”52 II 53

What most distressed the Sackler-family directors in 2011, however, was a midyear report that OxyContin sales were hundreds of millions less than had been forecast. All the bad news about opioids was taking its toll on the dispensing habits of doctors, who were writing lower-strength prescriptions. The two strongest Oxy doses, 60 mg and 80 mg, were off by 20 percent. They had Purdue’s biggest profit margins. By the end of the year, the Sacklers had “only” paid themselves $551 million. Although it was an enormous payout, it was a third of a billion dollars less than what they drew the previous year.54 As a result, the Sacklers (with a new family director that July, David Sackler, Richard’s son) exhorted the sales team in 2012 and 2013 to meet ever-higher targets. Richard Sackler blamed a sales dip over Christmas because many reps had taken off for the holidays. The company launched a quantitative research project that focused on patients who were long-term users of prescription opioids. Richard Sackler thought it might help give the detail team some fresh ideas about selling more Oxy at higher doses for longer periods.55 The company also produced and promoted videos encouraging doctors to prescribe liberally, kicked off a new marketing campaign called “Individualize the Dose,” and hired McKinsey consultants to develop innovative ways to generate more sales.56

The detail team reported that their one-on-one pitches were increasingly met with more questions, sometimes skepticism, especially from general practitioners. It had not helped that in May 2012, the Senate Finance Committee had launched an investigation into the degree to which money from Purdue, Johnson & Johnson, and Endo Pharmaceuticals had influenced seven of the country’s leading pain foundations.57 The probe was the idea of the committee’s chair, Montana’s Max Baucus, and the ranking minority member, Iowa’s Chuck Grassley. Both states were hard hit by the opioid epidemic.

The top target was the American Pain Foundation (APF), the country’s largest nonprofit dedicated to pain management. It promoted the idea that opioid painkillers were not the problem and the fault was overprescribing physicians. The APF was an industry mouthpiece that masqueraded as a patient advocacy organization. Over 90 percent of its revenue came from opioid manufacturers, with Purdue giving more than double any of its rivals.58 The day that the Senate Finance Committee announced its probe, the American Pain Foundation closed. In its final public release, it claimed that “due to irreparable economic circumstances” it could not remain “operational.”59 The widespread speculation was that the APF preferred shutting down rather than answer subpoenas for the production of documents that would expose the extent to which Purdue and its rival opioid manufacturers had controlled and manipulated it. The Senate investigation and the APF closure were front-page national news.III60

In March 2013, Purdue circulated an internal report with grim statistics and a frightening prediction. Not only had drug overdose fatalities in the U.S. tripled over a decade, but the tens of thousands who had died were just “the tip of the iceberg.” For everyone who died, there were over a hundred others battling dependence or abuse with prescription opioids.61 Purdue’s executives worried that such figures would prompt doctors to instinctively pull back further on their opioid prescribing.

There was a single bright spot for the company in the otherwise steady stream of negative news. On April 16 a small celebration broke out at its Stamford headquarters. Burt Rosen, Purdue’s Washington-based chief lobbyist, had called Richard Sackler with the news that the FDA had rejected the application of several manufacturers to approve a generic version of OxyContin.62 The patent that had expired on that same day was the one Purdue got in 1995 on the original formulation of OxyContin. Purdue had stopped manufacturing the original and replaced it in 2012 with its “new and improved” version featuring the abuse-deterrent coating.63 That version had a new patent that precluded generic competitors until 2025 (according to David Sackler, all the timing was a coincidence, something that seems very unlikely given that the patent monopoly was worth billions in extra years of profits).64

Purdue had been justifiably worried that a decision to allow generics would slash its selling price. Losing its unchallenged pricing power, the company forecast, would cause the average cost of a bottle of one hundred 40 mg pills to plummet from $450 to less than $100.65 The generic manufacturers had been joined by some pain management experts and patient advocates in arguing unsuccessfully that a denial was rewarding Purdue for having had an unsafe drug on the market for thirteen years before it developed the abuse-deterrent coating.

Not only was the FDA ruling a win for Purdue’s bottom line but it was the first time the drug agency had ever permitted a pharmaceutical company to make the claim on its label that its drug has “tamper-resistant properties.”66 In making that controversial ruling, the FDA said it had reviewed additional data submitted by Purdue that “was enough to show that the new version of OxyContin was safer, in its abuse resistance, than the original version.”67

By midsummer, it was back to disappointing news. Oxy year-over-year sales were almost $100 million less than expected. That was just in time for McKinsey’s finished report in August, Identifying Granular Growth Opportunities for OxyContin: First Board Update. It provided recommendations for how Purdue might “turbocharge the sales engine.” Among the short-term solutions, it suggested an increase in the annual quota for sales reps’ one-on-one doctor visits by 20 percent. The company had lost its laserlike concentration on courting the most “prolific prescribers.” Visits that tried to get low dispensers to write more prescriptions resulted in little increased revenue. According to McKinsey, the “more prolific group ‘write 25 times as many OxyContin scripts’ as the less prolific prescribers.” Moreover, McKinsey determined that after a Purdue sales rep visited one of the high-volume prescribers, they wrote even more scrips for opioids.68 (In 2015, Purdue tightened its compensation rules for the detail team; sales reps who did not visit enough “high value” prescribers lost bonus pay.)69

Finally, McKinsey suggested the detail team push OxyContin’s savings cards in neighborhoods with a high concentration of Walgreens pharmacies. Oxy sales were down 18 percent across all Walgreens pharmacies. The country’s second-largest retail pharmacy chain had two months earlier pled guilty to breaking the law by filling tens of thousands of illegitimate Oxy prescriptions. As part of its plea deal with federal prosecutors, Walgreens agreed to institute a long list of safeguards to ensure it could not happen again. The only way to boost the sales at the chain, said the McKinsey report, was for the Sacklers to lobby the top management at Walgreens to relax some of those new regulations for OxyContin.70

CVS, the nation’s largest retail pharmacy chain, was in the same predicament. The Sacklers discussed what to do at their September board meeting. They first voted another payment to themselves, bringing their 2013 total to $400 million.71 Then all agreed if they were not successful at getting the two retail chains to find a workaround for the government-imposed safeguards, Purdue should look into placing its star drug into mail order pharmacies or even consider selling Oxy directly. The last idea was not realistic. No pharmaceutical firm had ever been allowed to sell a controlled substance straight to consumers.

Before the year ended, Burt Rosen, Purdue’s in-house lobbyist, approached Richard Sackler about a sensitive matter, “concerns over our internal documents.”72 Rosen worried that Purdue’s files might contain incriminating information. The multiplying lawsuits and government probes made it ever more likely those documents might one day be subpoenaed and made public. Richard Sackler did not seem too troubled. Rosen then raised it with Jonathan Sackler, who also seemed unperturbed.

Richard Sackler had had several small strokes by this time and his health was not good. Purdue brought in five outside directors to serve with the nine Sackler directors. The most persistent rumor was that David Sackler, Richard’s son, might replace his father as Purdue’s chief.73 It was evident that whoever took control of the family-run drug empire was going to be safeguarding one of America’s largest personal fortunes. The Sackler family entered the Forbes “Richest Families” list with an estimated net worth of $14 billion in 2014.74 The magazine noted that twenty years of sales of Purdue’s wildly popular opioid product was “why they edged out families like the Busches, Mellons and Rockefellers.”75

Copies of Forbes passed around headquarters. Some of the family thought it was aspirational and might encourage top Purdue executives and the sales team to redouble their efforts. No one at the company mentioned that the same year the Sacklers cracked the elite Forbes list, a record nineteen thousand Americans had died of prescription opioids, mostly OxyContin. David Sackler, a Purdue director for six years starting in 2012, was the only family member who later commented on the drug’s deadly legacy. In a 2019 interview in Vanity Fair in which he tried to do some belated damage control for the much besieged family, he claimed, “We have so much empathy.… We feel absolutely terrible.”76

I. The DEA ultimately fined McKesson and Cardinal Health $341 million for filling millions of OxyContin from “suspicious orders.” After that, the distributors bypassed Rannazzisi and went to his superiors. “They complained to Congress that DEA regulations were vague,” recalled Rannazzisi, “and the agency was treating them like a foreign drug cartel.” By 2013, he recalls, “there was a sea change in the way prosecutions of big distributors were handled. Cases… that once would have easily been approved, now weren’t good enough.” McKesson, Cardinal, and AmerisourceBergen were subsequently named as plaintiffs in the consolidated opioid litigation in federal courts. In April 2019, they reached their first settlement agreement. West Virginia got $37 million from McKesson, $20 million from AmerisourceBergen, and $16 million from Cardinal. The trio only paid the fines, none admitted any wrongdoing. In late October, on the eve of the first opioid trial scheduled in Ohio, McKesson, AmerisourceBergen, and Cardinal agreed to pay $215 million to the two plaintiffs, Cuyahoga and Summit Counties. Another defendant, Israel-based Teva Pharmaceutical Industries, settled at the same time for $20 million cash and $25 million in addiction-treatment medications. None admitted wrongdoing.

II. In dozens of cases filed against Purdue since 2016, state attorneys general included Johnson & Johnson, Ortho-McNeil Janssen, Endo Health, Allergan, and Watson Pharmaceuticals in their complaints. In February 2019, the Oklahoma attorney general filed a suit charging that Johnson & Johnson had acted as “a kingpin behind the public-health emergency, profiting at every stage.” Besides making and selling its own opioid-based products, the Oklahoma AG said the reason J&J had acted like a drug kingpin was that it had used foreign subsidiaries in Tasmania to grow and process raw opium that it then sold to other drugmakers for the ingredients used in two thirds of all painkillers. On August 26, 2019, a judge ruled against Johnson & Johnson. He found the company liable for overhyping the benefits of its opioids and downplaying the risks. It was fined $572 million. That was reduced in November to $465 million. Johnson & Johnson has appealed.

III. It took a year of hearings and document production before its draft conclusions were ready. Those have never been released. In January 2014, Baucus left to become President Obama’s ambassador to China and Grassley switched to the Judiciary Committee. Their replacements, Utah’s Orrin Hatch and Oregon’s Ron Wyden, kept the report sealed. That it is secret years after its completion has spawned dozens of conspiracy theories including one that the U.S. government has covered up a Sackler/OxyContin and Sinaloa Mexican Cartel/heroin alliance. In fact, the progressive Senator Wyden, no friend to the pharmaceutical industry, has explained that the Senate rules “prohibit the release of documents collected in the course of an investigation outside the context of an official report.”