December 6, 2021

Mental & Emotional Health

#186 – Patrick Radden Keefe: The opioid crisis—origin, guilty parties, and the difficult path forward

“Today the opioid crisis is a heroin and fentanyl crisis… absent Oxycontin, we might not be where we are today.” —Patrick Radden Keefe

Read Time 58 minutes

Patrick Radden Keefe is an award-winning staff writer at The New Yorker and the bestselling author of Empire of Pain: The Secret History of the Sackler Dynasty. In this episode, Patrick tells the story of the Sackler family and Purdue Pharma – makers of the pain management drug OxyContin, providing the backdrop for the ensuing opioid epidemic and public health crisis. He reveals the implicit and sometimes explicit corruption of all parties involved in the development, approval, and marketing of OxyContin, leading to a cascade of unintended consequences including addiction and death. He explains the unfortunate lack of accountability for the current crisis, as well as what it all means for those with legitimate pain management needs. Finally, he examines the difficult path ahead towards finding a solution.


We discuss:

  • Patrick’s investigation into distribution and use of drugs in our society [3:55];
  • The scale of of the opioid crisis [9:15];
  • The Sackler brothers: family life, career in the pharmaceutical industry, and role in the current crisis [11:45];
  • Purdue Pharma: origins, early years, and move towards pain management drugs [17:30];
  • The development of OxyContin: its conception, marketing, and the controversy around the FDA approval process [25:30];
  • Early reports of OxyContin addiction and unintended consequences and how Purdue Pharma sidestepped responsibility [40:45];
  • The many paths to addiction and abuse of OxyContin and the ensuing downfall of Purdue Pharma [47:15];
  • Peter’s personal experience with OxyContin [57:00];
  • Pain—the “fifth vital sign,” how doctors are trained in pain management, and the influence of money [1:08:00];
  • Other players that helped facilitate the eventual opioid crisis [1:16:15];
  • Lack of accountability following the investigation and prosecution of Purdue and the Sackler family [1:23:30];
  • Legacy of the Sackler family and their disconnect from reality [1:34:45];
  • Patrick’s views on the regulation and use of pain management drugs [1:42:15];
  • The difficult path forward [1:44:45]; and
  • More.


*Intro notes*

  • The guest this week is Patrick Radden Keefe, an award-winning staff writer at The New Yorker magazine and a New York Times bestselling author
  • His most recent book is about the opioid epidemic

Figure 1. Patrick’s book about the opioid epidemic.  Image credit:

  • Peter has been wanting to do a podcast on the opioid epidemic for some time, and he’s been trying to think of the right way to do it
  • Recently, he saw the HBO documentary, The Crime of the Century, and thought it was a really good and thorough overview of the problem

Figure 2. Movie Poster.  Image credit: by Studio and or Graphic Artist 

  • This is a problem that has many layers to it, right? 
    • It has the organizations that actually make these drugs, so the producers and the pharma companies
    • It has the organizations that distribute these drugs between the producers and the end-stage or end-use retailers, so the intermediaries
    • It has the retail side of things, where these drugs are purchased
    • The physicians who prescribe these drugs
    • The patients who use these drugs
    • The enforcement agencies that regulate them
    • The FDA that approves these drugs
    • The medical advocacy groups that provide guidance to physicians about them
  • Consider the landscape of this problem and all of the actors just listed, each one of them plays some role in the current situation
    • Half a million people have died in the past 25 years from opioid overdose 
    • Opioid overdose now represents the leading cause of accidental death in the United States
      • Ahead of car accidents, gunshots, and things like that
  • Patrick’s book goes straight to the heart of the matter to explain: 
    • How did this begin? 
    • What was the thin end of the wedge that created this epidemic? 
    • He makes a very compelling case that it was the company, Purdue Pharma, a privately held company run by the Sackler family
  • This episode will discuss at great length the history of the Purdue Pharma Company and its management team
    • About the implicit and sometimes explicit corruption that existed 
    • About the other players in this channel, the physicians, the regulators, the politicians
      • none of whom really get off scot-free in this assessment
  • This is a bit of a depressing episode
    • There is not much optimism that a solution is in hand and that 5 years from now, one will look back at this and marvel at how easily it was able to be solved
  • Peter feels it is important to expose and shed some light on how the opioid crisis came to be


Patrick’s investigation into distribution and use of drugs in our society [3:55]

  • Patrick has always been interested in drugs as a subject
    • The way in which drugs fit into our society
    • How we feel about them
    • Which drugs are licit, which drugs are illicit
  • He wrote a big piece a number of years ago about the legalization of cannabis in Washington State
  • He is very interested in this idea that you have this existing industry, this pot industry that’s been around for decades, and with the stroke of a pen at midnight it’s legalized 
    • What does that look like? 
    • How does it turn into a taxed and regulated economy? 

Mexican drug cartels

  • He had done a lot of writing on Mexican drug cartels
    • Before he was full-time at The New Yorker, he did a cover story for The New York Times Magazine in 2012 about the Sinaloa drug cartel, Cocaine Incorporated
      • To put this in context, at the time he had to explain to the editors of The New York Times Magazine who Chapo Guzmán was
  • He wanted to do sort of a Harvard Business School case study of a cartel
    • He wanted to look at it as a multi-billion dollar transnational commodities enterprise
    • He was really interested in how they diversified and how vertically integrated they were
  • The Sinaloa cartel dealt in cocaine, marijuana, heroin, and methamphetamine
  • One of the questions that grew out of that research had to do with the surge in heroin
    • After 2010, huge volumes of Mexican heroin started coming across the border in ways that hadn’t been seen before in the US; this was the riddle he started with
    • He started with this question of why is there a sudden uptick in heroin trafficking in the US
      • The answer was the opioid crisis

Complex web of entities involved in the opioid crisis

  • He started out with an inquiry that was solidly grounded in the realm of the illicit drug trade and found his way into the world of the FDA regulated legal drug trade with OxyContin and Purdue Pharma
    • So he started looking into the origins of the opioid crisis
    • He then discovered that this company (Purdue) was owned by the Sackler family 
      • This blew his mind, the idea that this family that’s quite well known for philanthropy had made such a huge fortune on a drug with such a controversial legacy
  • A long time ago when Peter was trying to get his mind around how many actors there were in the opioid crisis, he drew on a piece of paper
    • It started on the left with the producers
      • Not illicit chains but pharma companies of which Purdue was the champion of them
    • Then there were the distributors or intermediaries
      • The McKessons and the Cardinals of the world
        • He actually knew a lot about McKesson through a previous life 
        • He was intimately familiar with what companies like McKesson did and how they were able to distribute products from the producers to the retail, the pharmacy, the CVSs of the world, so that became the third actor
    • The 4th actors were the FDA (the approval process of the drug) and the DEA (enforcement)
    • There are policymakers that create the policies that allow these entities to exist
    • There are the providers, people that write the prescriptions for these things
    • And ultimately there are the patients
  • The study of Purdue Pharma and the Sacklers, more than any other single entity in this entire chain he just explained, can provide a greater context of what we’re up against 
  • Patrick notes that the nuance of all the actors in this crisis often gets lost
  • He writes stories where his interests lead him, stories he thinks are interesting and important and that will be interesting to readers
  • He doesn’t claim his work is the be-all and end-all in understanding the opioid crisis
    • This is an incredibly complex public health crisis that has unfolded over the course of a quarter of a century


The scale of of the opioid crisis [9:15]

  • At  least a half a million people who’ve died from opioid overdoses since the mid to late 1990s
  • By some estimates, there are two plus million Americans today struggling with an opioid use disorder of one sort or another
  • Opioids are a pretty capacious category
  • Think about the death toll today, the Sacklers would be quick to say, today, people are dying in very large numbers from heroin and fentanyl overdoses, not from OxyContin or from most prescription painkillers
  • This problem has transitioned into an illicit drug problem
  • So why did Patrick pick OxyContin? Why pick the Sacklers?

{end of show notes preview}

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Patrick Radden Keefe

Patrick grew up in Dorchester, Massachusetts and went to college at Columbia. He received masters degrees from Cambridge University and the London School of Economics, and a JD from Yale Law School.  He is the recipient of a Guggenheim fellowship, and fellowships from the Rockefeller Foundation, the New America Foundation, the Woodrow Wilson International Center for Scholars, and the Cullman Center for Scholars and Writers at the New York Public Library.  

Patrick is an investigative journalist and has written extensively for many publications.  He is an award-winning staff writer at The New Yorker magazine.  His work has appeared in The New York Review of Books, The New York Times Magazine, Slate, and other publications.  He received the National Magazine Award for Feature Writing in 2014, and was a finalist for the National Magazine Award for Reporting in 2015 and 2016.

He is the author of four books: Chatter, The Snakehead, Say Nothing, and Empire of PainSay Nothing received the National Book Critics Circle Award for Nonfiction, the Orwell Prize for Political Writing, and was selected by Entertainment Weekly as one of the “10 Best Nonfiction Books of the Decade.” The Rolling Stone describes Keefe as “an obsessive reporter and researcher, a master of narrative nonfiction”.  

Patrick is also the writer and host of WIND OF CHANGE, an 8-part podcast series from Pineapple Street Studios, Crooked Media and Spotify, which investigates the strange convergence of espionage and pop music during the Cold War and was named the #1 podcast of 2020 by The Guardian.  [

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  1. I think it is amazing that NO ONE ever wants to blame the Governing Bodies for making access to OxyContin sooooo difficult. If those people that are addicted were able to access the drug (manufactured in a regulated facility) they would not be turning to the street drugs that are laced with fentanyl and dying. In my opinion, the fentanyl drug deaths are on the hands of the government.

  2. Very important conversation about a complex challenge(s). While I stipulate to most everything said about the role of Purdue and the Sacklers, I have been intrigued by the failure of communities and local enforcement (In addition to state and federal stakeholders) to stop the very well known unlawful distribution of opioids including Oxycontin at local pharmacies in the late 1990 and early 2000. For example a congressional hearing was held in the Philadelphia area in 2001 where all the relevant factors regarding oxycontin abuse, overdose, marketing were discussed. Multiple news reports, congressional hearings were held at that time that “exposed” the dangers of the medication. What were the factors that led to the failure of accountability? Would a more empowered and engaged citizenry make a difference?
    In the early part of 2022 I will be launching a citizen focused project to better address the complexity of the pain and opioid crisis .

    Regarding The fifth vital sign. It originated at John Hopkins, perhaps when Dr. Attia was doing his surgical training.
    ” In 1995, James Campbell, then director of the Blaustein Pain Treatment Center at The Johns Hopkins Hospital and president of the American Pain Society, argued that pain should be measured as a fifth vital sign, alongside blood pressure, temperature, heart rate, and respiratory rate.”
    This was because health care professionals often ignored patients’ suffering from pain. There was no intent to have everyone take an opioid.
    The Fifth Vital Sign is still in clinical use

    A often overlooked factor in progression to addiction ( Rather than dependence) is the role of environment, traumatic experiences, marginalization, alienation and other societal factors. Here is quote from Bobby Kennedy in the 60’s true than as well as now.
    “Now, more than at any other time in our history, the addict is a product of a society which has moved faster and further than it has allowed him to go, a society which in its complexity and its increasing material comfort has left him behind. In taking up the use of drugs the addict is merely exhibiting the outermost aspects of a deep-seated alienation from this society, of a combination of personal problems having both psychological and sociological aspects.”
    Kennedy continued,
    “The fact that addiction is bound up with the hard core of the worst problems confronting us socially makes it discouraging at the outset to talk about solving’ it. Solving’ it really means solving poverty and broken homes, racial discrimination and inadequate education, slums and unemployment….”

    A substantial number of young people get the opioids and other drugs (Benzo’s, sedatives) from their family’s medicine cabinets.

    Thanks for your excellent podcast

  3. An riveting podcast! Thank you for such a detailed exposé.

    Canadians have been running out of beer & popcorn while staring at American TV news reports, in dumbfounded amazement.

    John Oliver offers another excellent (albeit less detailed) 24 minute recap: 

    … wherein is embedded this worthy sidebar link which lampoons the Sacklers’ own PR efforts.

    This just in:

    BNNBloomberg: A $10 Billion Question: Did Sacklers ‘Abuse’ Purdue Bankruptcy?

    Justice delayed may yet still be served.

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