July 9, 2021
Introduction:
The U.S. is currently experiencing a horrendous opioid epidemic. It began about 20 years ago and has ravaged the entire country. In this post, we will review the events that triggered this catastrophe. As we will show, the “taproot” for this epidemic can be traced to a single product, OxyContin. It was first marketed in 1997 by a pharmaceutical company called Purdue Pharma. Purdue Pharma is a privately-owned corporation that was founded and has been run by a single family, the Sackler family. In this post, we will review the history of the marketing of OxyContin. And we will show how the Sackler family marketed an opiate product that they touted as being resistant to addiction. Their product was marketed by sales representatives that pitched OxyContin as safe and non-addictive; in addition, it was claimed that it could not be abused. As we now know, virtually all of the claims made by Purdue Pharma for their product were false, and the company realized that they were false.
In order for the opioid epidemic to take hold, a number of other American enterprises had to fail to stop Purdue Pharma, regulate its product and verify their claims. U.S. regulatory agencies such as the Food and Drug Administration and the Drug Enforcement Agency, were either co-opted or foiled. The medical community, that should have been vigilant against allowing an extremely strong opioid to be prescribed for routine chronic pain, was influenced by advocates for a “new pain management” paradigm. Many of the foremost physicians in this movement claimed that the U.S. was experiencing an “epidemic of pain” that required the use of strong opioids to treat. And efforts to hold Purdue Pharma accountable were routinely stymied by a bevy of high-priced and well-connected lawyers, whose efforts allowed Purdue Pharma to continue selling their deadly product until our present-day plague of addiction became impossible to ignore.
There will be many books written about the opioid epidemic. Already we have three fine books on this topic. The first was Barry Meier’s Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic. It was originally published in 2003; an expanded and revised edition was published in 2018. Barry Meier co-authored the first significant article linking OxyContin to a growing wave of drug abuse. After publication of his book, Meier continued to follow the story as it unfolded (see here and here). Meier correctly linked Purdue Pharma and its opiate drug OxyContin as a central feature of the epidemic. As we will see, the opioid epidemic continued to grow and has now reached horrific levels. Meier’s revised 2018 edition tracks the OxyContin – drug abuse story until 2018.
Figure I.1: Barry Meier’s book Pain Killer: An Empire of Deceit and the Origin of America’s Opioid Epidemic, first issued in 2003 and re-issued in 2018.
A second book is Dreamland: The True Tale of America’s Opiate Epidemic, by Sam Quinones. It was published in 2015. Quinones outlines the origin of the opiate epidemic from several different angles. He discusses the introduction of OxyContin by Purdue Pharma, and its central role in the opioid epidemic. He shows how various communities, particularly in the region around Portsmouth, Ohio, were completely devastated by this drug abuse. Quinones also reviews the introduction of black tar heroin from the Mexican state of Narayit; he relates how this heroin became a drug that many substituted for opiate pharmaceuticals.
Figure I.2: Sam Quinones’ 2015 book, Dreamland: The True Tale of America’s Opiate Epidemic.
A third book is Patrick Radden Keefe’s Empire of Pain: the Secret History of the Sackler Dynasty, which was published in 2021. Keefe’s first publication on the Sackler family and OxyContin was a New Yorker article in Oct. 2017. His book provides a deep dive into the secretive Sackler family, its family history in business, and the marketing of OxyContin. The focus throughout is on the family, how they ran the company Purdue Pharma, and the many twisted steps that led to the current American opioid epidemic.
Figure I.3: Patrick Radden Keefe’s 2021 book Empire of Pain: The Secret History of the Sackler Dynasty.
In 2016, the Los Angeles Times published a three-part investigation of Purdue Pharma, their drug OxyContin, and the growing opioid addiction problem in the United States (here are links to part 1, part 2 and part 3 of that report). Part 3 of that report details the overseas marketing of OxyContin through Purdue Pharma’s international company Mundipharma; although that is not a major part of this post, the overseas extension of such a controversial product bears remarkable similarities to the actions of the tobacco industry in moving overseas, once their products had gained a toxic reputation in the United States.
In this first part of our post we describe some of the history of the Sackler family’s involvement in the medical and advertising industries prior to the Purdue Pharma saga, as that history establishes some of the modus operandi that characterized their later actions marketing OxyContin.
Part I: The Patriarch
Arthur Sackler was born in Brooklyn in 1913. He was the oldest of three sons of Isaac and Sophie Sackler. Arthur went to Erasmus High School in Flatbush, where he began to demonstrate the personality traits that would take him far. Arthur was a fine student, and in addition he had boundless energy. Even in high school, he was taking on additional jobs and entrepreneurial activities.
Figure I.4: Arthur Sackler, the patriarch of the Sackler family dynasty.
Working on the high school yearbook, Arthur set up a photography business that handled the yearbook pictures. One of the businesses that bought space in the yearbook was a chain called Drake Business Schools. Arthur managed to talk them into hiring him as their advertising manager. Another of Arthur’s qualities was his relationship with his brothers Mortimer and Raymond. When Arthur had ideas for business ventures, he would often hand them off to his brothers; or perhaps more precisely, he would order his brothers to take on various projects. For example, “Arthur arranged for his brothers to sell advertising for The Dutchman, the student magazine at Erasmus. They persuaded Chesterfield cigarettes to run ads aimed at their fellow students. This generated a nice commission.”
Figure I.5: The three Sackler brothers, Raymond, Arthur and Mortimer Sackler.
Arthur graduated from New York University in 1933 and was accepted into NYU’s medical school. Even as a medical student, Arthur somehow found the time to work part-time as a copywriter for Schering, a German pharmaceutical company. After completing his medical degree, Arthur took a job at the Creedmoor Psychiatric Center in Queens. At that time, psychiatric patients were warehoused in large centers such as Creedmoor. The understanding of the origins and treatment of mental illness was still at a very early stage. The prevailing viewpoint was that such conditions were hereditary, and that nothing could be done except to isolate them from “normal” society, and to keep them from injuring themselves and others. A competing view of mental illness was the Freudian theory that mental illness was acquired through the early experiences of the patients.
Regardless of the cause of mental illness, patients incarcerated in mental hospitals had a very poor quality of life. Arthur Sackler was particularly unimpressed with the prevailing treatment for schizophrenia, electroshock therapy. Although it provided many patients with some relief from psychotic episodes and severe depression, Arthur believed that mental illness must have a biochemical component, and as such there must be chemicals that could treat these terrible symptoms.
At Creedmoor, Arthur Sackler met Dr. Marietta Lutze, who had applied for a job at the facility. Sackler asked her out and courted her. Marietta found Arthur to be a force of nature. He bombarded her with gifts and would call her at all hours of the night, insisting on seeing her. They carried on a torrid relationship for some time, until Marietta Lutze discovered a slight problem: Arthur Sackler was married and had two children. At this point, she was forced to confront some unusual personal characteristics of Arthur.
First, Arthur Sackler was incredibly secretive. He divulged little of his personal life to others. Later in life, not only would he refuse to give interviews about himself, but he also took great pains to hide himself and his role in the many corporations that he owned. In fact, Arthur Sackler had married his first wife Else when he was in medical school. At the time, med school students were forbidden to marry; so Arthur simply married Else and kept that information secret. A second personality trait was that Arthur was deeply amoral. He went to great lengths to persuade Marietta that they could simply work and live together as a couple without having to get married (and perhaps more importantly, without Arthur having to get a divorce).
Eventually Arthur divorced Else and married Marietta. But he continued to see Else frequently, and occasionally he and Else went on trips together. After Arthur’s death, it turned out that various companies in which Arthur was a founder and a major factor were actually “owned” by others. In some cases, those were his brothers Mortimer and Raymond. Arthur set them up in various businesses in which he was involved. During his lifetime, it was not always clear who was in charge of various Sackler enterprises, as Arthur tended to boss his little brothers around. In one important case, a company of Arthur’s was actually “owned” by his ex-wife Else Sackler.
Several years later, Arthur met Jillian Tully, a young woman who was working at an advertising agency in London. Arthur struck up a romance with “Jill,” and declared his love for her and his wish to spend all of his time with her. There was a slight problem in that Arthur was still married to Marietta, and that divorce would be difficult. But Arthur did not see that as an insurmountable obstacle. Arthur proposed that he and Jill could simply behave as though they were married. For a while, that is just what they did. Arthur introduced Jill to his friends as his wife. Jill moved to Manhattan, where she became the third woman calling herself “Mrs. Arthur Sackler.” Jill even legally changed her name to “Jillian Sackler,” despite the fact that Arthur was actually married to Marietta and not her (eventually, Arthur divorced Marietta and married Jill).
The first big medical breakthrough by the Sackler brothers occurred when they performed electroshock on a rabbit. They hooked one of the rabbit’s ears up to an electroshock machine and turned it on. They noticed that immediately following the current from the machine, the blood vessels in the rabbit’s ear filled with blood. But a few seconds later, the blood vessels in the rabbit’s other ear (which had not been connected to the machine) also swelled up. The Sacklers hypothesized that the electric current might have caused some chemical to circulate in the rabbit’s bloodstream.
The brothers knew that a chemical called histamine was released when tissues were injured, and this caused blood vessels in the vicinity to dilate. They speculated that electroshock might release histamine in the patient’s head; the histamine would cause the blood vessels to dilate, bringing more oxygen to the brain. They further hypothesized that perhaps the release of histamine might be a major reason why electroshock therapy gave positive relief to mental patients.
So the Sacklers began experimenting giving histamine to patients at Creedmoor. The results they obtained were quite promising. On a sample of forty schizophrenic patients, one third of them improved sufficiently that they could be released from the hospital. They also found patients who responded positively to histamine treatments, but had not improved with any other treatments. The brothers published more than one hundred papers on their work in medical journals. They also received much publicity for their research and, guided by Arthur’s gift for advertising, some of this was really over the top. “An article in Better Homes and Gardens suggested, with ample hyperbole, that “the chemical activity theory of the Sacklers is as revolutionary, and almost as complicated, as Einstein’s relativity.”
Arthur Sackler, the Father of Medical Advertising:
In 1942, William McAdams had hired Arthur Sackler to focus on the pharmaceutical sector at his advertising agency, the William Douglas McAdams agency. In the beginning, Sackler was still employed full-time as a psychiatrist at Creedmoor Hospital, and was working part-time for McAdams. William McAdams had experienced great success when he advertised Squibb’s cod liver oil not to the general public, but to doctors and prescribers. Arthur Sackler immediately realized the power of direct advertising in the medical field. Sackler placed ads in medical journals, and he also designed promotional material that was sent directly to doctors’ offices.
Even though the McAdams work began as a part-time job, Arthur was so successful in his advertising that in two years Sackler was made president of the firm; and in another two years, Sackler bought the McAdams agency from its founder. Arthur retained the name of the firm, which tended to conceal his role as the firm’s owner. However, his medical advertising campaigns had been so successful that he gained a reputation as a brilliant innovator. While previous advertising campaigns directed at physicians or the medical profession had been sober and serious, representing a “just the facts, Ma’am” mentality, Arthur’s ad campaigns were much flashier.
Arthur specialized in adopting “the seductive pizzazz of more traditional advertising – catchy copy, splashy graphics – and market[ing] directly to an influential constituency: the prescribers.” He would produce colorful ads in medical journals; he also distributed literature that was mailed to physicians but could also be handed out to patients. In addition, Sackler signed up doctors who were paid to endorse various pharmaceuticals. Such tactics had previously been used to market cigarettes to the general public (“four out of five doctors who smoke recommend Camels”), but in this case doctors were pushing medical products to their colleagues. Part of Arthur’s success lay in the fact that he believed deeply in the power of medicine to improve the life of individuals. He had a deep-seated belief in the benefits of medicine, and this was borne out in his optimistic (even hyperbolic) advertising campaigns.
Another of Arthur’s innovations was in the use of sales representatives to market a company’s new products to physicians. A particular example of this was with the McAdams agency’s largest customer, Pfizer. In 1949, Pfizer began marketing a new antibiotic, Terramycin. They began their marketing campaign to physicians with eight sales reps. However, they were so successful that in less than two years Pfizer had a team of 300 sales reps; and in eight years this would grow to 2,000. In addition to bombarding doctors with advertising brochures and sales pitches, Pfizer sales reps would also offer to take doctors out to lunch or dinner. Although Arthur Sackler insisted that his promotional campaigns were mainly “educational,” his sales reps were strongly motivated to “brand” their own products, and pressure doctors to prescribe pharmaceuticals by brand name.
Arthur Sackler vehemently denied that taking doctors out for complimentary meals constituted a sort of “bribe” on behalf of the products he was pushing. He insisted that physicians were so intelligent that their minds could not be changed with such a small reward. In fact, Sackler knew quite well that physicians would often recommend a particular medicine in return for a meal or “swag” merchandise worth roughly $20.
Arthur Sackler’s innovative ideas, drive and creativity made the McAdams agency the top performer in the medical advertising field. The decision to focus their efforts on advertising in the area of pharmaceutical drugs had been exceptionally profitable. The McAdams firm had one major rival, the L.W. Frohlich agency. Advertising Age called McAdams and Frohlich “the two top ones in the field.” They appeared to dominate in their fields, signing up the largest and most successful pharmaceutical firms. Ludwig Wolfgang “Bill” Frohlich stated that the pharma industry was characterized by a “competitive zeal.” His rival Arthur Sackler similarly claimed that “We operate in an area of incredibly intense competition.”
Figure I.6: L.W. “Bill” Frohlich, head of a major pharmaceutical advertising agency.
The reality was much more complex. Bill Frohlich had briefly worked for Arthur Sackler as a type designer in the 30s, when Sackler worked for Schering pharmaceuticals. And Sackler had secretly bankrolled Frohlich’s advertising agency; in fact, Patrick Keefe suggests that the Frohlich agency might have been Sackler’s idea in the first place. So the perception that the McAdams and Frohlich agencies were fierce rivals was totally false: the two firms were actually acting like two different departments of the same firm. Both Arthur Sackler and Bill Frohlich went to great lengths to keep anyone from discovering the close links between their respective firms.
In the advertising business, conflict of interest rules prevented a firm from taking on as clients two companies that were making competing products. But because it was not realized that Arthur Sackler was a silent partner in the Frohlich agency, McAdams and Frohlich were able to separately sign with competing firms. In effect, the two agencies simply divided up many of the biggest pharmaceutical agencies between them.
Arthur Sackler’s brothers Mortimer and Raymond were both principals in the McAdams advertising agency. The Sacklers and Bill Frohlich had drawn up two overarching legal agreements regarding the status of their companies. The first was a four-way agreement between Arthur, Mortimer and Raymond Sackler, and Bill Frohlich. This was an agreement reminiscent of the central theme of “The Three Musketeers.” In the 1960s, the three Sackler brothers and Bill Frohlich established a first agreement commonly known as a “tontine.” Upon the death of one of the four members, the companies owned by these four would then revert to the remaining three survivors (subject to reasonable assets being provided to the heirs of the deceased). As the survivors then died off, ownership of their companies would then revert to the remaining survivors. When the final survivor died off, the companies were to be sold and the proceeds given to charity. The lawyer Richard Leather had written up the agreement among the four parties.
However, the first tontine referred only to domestic companies. A second “Musketeers” agreement was established that dealt with foreign companies. The line of succession was the same — as each individual died off, ownership of the foreign companies would revert to the survivors; and after all of them passed away, the companies would be sold and the proceeds donated to charity. However, in this case the signatories were Raymond and Mortimer Sackler and Bill Frohlich, but did not include Arthur. As we will see later, these secret agreements would turn out to be extremely important, and quite divisive.
The King of Tranquilizers:
In 1957, chemist Leo Sternbach made a fascinating discovery. He found that a particular compound, chlordiazepoxide, appeared to have many beneficial effects. It seemed to make people cheerful, without producing the side effect of drowsiness, which was a property of the current best-selling tranquilizer, Miltown. Furthermore, when tested by Sternbach’s pharmaceutical company Roche, the new drug (which Roche named “Librium,” a combination of ‘liberation’ and ‘equilibrium’) was effective against conditions such as “anxiety, depression, phobias and suicidal thoughts.” Librium appeared to be the “minor tranquilizer” that was being sought by many pharmaceutical companies.
The medical community had “major tranquilizers” such as Thorazine. However, Thorazine was not only extremely powerful, but it had serious side effects that made physicians wary of using it for anything but serious psychosis. However, it appeared that the side effects of Librium might be minor, and that it might be prescribed to the general public to treat less serious psychological conditions. Roche contracted with Arthur Sackler’s McAdams advertising agency to run the publicity campaign for Librium.
For Librium, Arthur Sackler used all of the methods that he had perfected in earlier campaigns. He persuaded Roche to undertake a lavish publicity campaign. Teams of sales reps were assigned to descend on doctors’ offices around the country. Roche placed “extravagant advertising spreads” in major medical journals. The McAdams agency also solicited testimonials from doctors attesting to the efficacy of Librium. Later, critics of these tactics observed that these “testimonials” and claims from Roche were backed up with little or no evidence.
But the most effective aspect of Arthur Sackler’s ad campaign for Librium was his ability to describe Librium as not just a ‘minor tranquilizer,’ but a brand-new cure for what Sackler called “anxiety.” The wording was brilliant – the Cold War was raging; civil-rights protests were beginning in earnest; the US and Russia were still engaged in nuclear weapons testing. Why, perhaps half of Americans might describe themselves as “anxious.” The advertising campaign for Librium was wildly successful. In 1965, five years after the launch of Librium, 15 million Americans had taken it.
It turned out that Leo Sternbach had discovered yet another ‘minor tranquilizer,’ diazepam. It had many of the same effects as Librium, but it could be administered in significantly lower doses. Roche called this new tranquilizer Valium, and they rolled out Valium in 1963. But this presented Roche (and Arthur Sackler) with a challenge: both Librium and Valium had very similar effects. Would not the marketing of Valium cut into the sales of Librium, which was just taking off?
Figure I.7: Yellow Valium (Diazepam) tranquilizer tablets.
Once again, Arthur Sackler devised a clever advertising campaign for Valium. His method here was to assert that Librium and Valium should be the medicines of choice for apparently different conditions. While Librium was pitched as being the drug of choice for “anxiety,” Valium was said to be most effective against “psychic tension.” This was a brilliant strategy on several levels. First, it seemed that the two drugs were not really competing against one another; for example, the ad campaign for Valium stressed that it might be used for sports medicine. However, in practice the categories of “anxiety” and “psychic tension” were sufficiently vague that each could be seen as including the other.
Another feature of these tranquilizers was that they were predominantly marketed to women. Sackler quickly learned that tranquilizers were being prescribed for women more often than men; so his ad campaigns tended to stress their value to the modern American woman. In addition, Sackler’s ad campaign tended to lean heavily on sexist stereotypes common at that time – “the neurotic singleton, the frazzled housewife, the joyless career woman, the menopausal shrew.” Surely all of these would benefit from a prescription for Valium?
In 1966, the British rock band The Rolling Stones released a single, Mother’s Little Helper. Written by Mick Jagger and Keith Richards, it was a sarcastic description of the use and abuse of tranquilizers. Some people assert that the drug in question was Valium (diazepam), while others claim that it was Miltown (meprobamate). As we have mentioned, those tranquilizers were widely marketed to women, on the grounds that females were subjected to stress and that they needed “something to calm her down,” even though “she’s not really ill.”
Figure I.8: Record jacket for Mother’s Little Helper by the Rolling Stones.
The lyrics for Mother’s Little Helper represent a brutal parody of the arguments behind the marketing campaigns for the tranquilizers. They also highlight the possibility of abuse from these drugs. The song also turns the tables on the critics of rock musicians and their penchant for illegal drugs, as Jagger and Richards point out that potentially dangerous drugs are also being marketed to suburban women.
What a drag it is getting old
“Kids are different today, ” I hear every mother say
“Mother needs something today to calm her down.”
And though she’s not really ill, there’s a little yellow pill
She goes running for the shelter of her mother’s little helper
And it helps her on her way, gets her through her busy day
“Things are different today, ” I hear every mother say
Cooking fresh food for her husband’s just a drag
So she buys an instant cake, and she burns a frozen steak
And goes running for the shelter of her mother’s little helper
And two help her on her way, get her through her busy day
Doctor, please, some more of these
Outside the door, she took four more
What a drag it is getting old
“Men just aren’t the same today, ” I hear every mother say
They just don’t appreciate that you get tired
They’re so hard to satisfy, you can tranquilize your mind
So go running for the shelter of a mother’s little helper
And four help you through the night, help to minimize your plight
Doctor, please, some more of these
Outside the door, she took four more
What a drag it is getting old
“Life’s just much too hard today, ” I hear every mother say
The pursuit of happiness just seems a bore
And if you take more of those, you will get an overdose
No more running for the shelter of a mother’s little helper
They just helped you on your way, through your busy dying day
Hey
Here is the audio of the Stones performing Mother’s Little Helper.
Shortly after its release, Librium became the most prescribed drug in America. In 1968, Valium overtook Librium, even though Librium remained in the top five of the most-prescribed drugs. Sales of Valium were simply astonishing. By 1975, 60 million prescriptions had been written for Valium. It was the first drug in history to reach $100 million in sales. Roche became one of the largest companies in the world. Of course, Arthur Sackler was handsomely rewarded for his advertising efforts. Part of his deal with Roche involved bonuses that increased along with the volume of pills that were sold.
Arthur Sackler would have been a wealthy man even if he had never been involved with the Librium and Valium promotions. But his association with Roche made him an exceptionally wealthy man. As with most of his businesses, Arthur had brought his brothers Mortimer and Raymond into the McAdams agency; so they also were beneficiaries of the great good fortune that arose from the Roche tranquilizers. Through the 1960s, the three Sackler brothers alike shared in the wealth generated by the McAdams advertising agency, as well as from several businesses purchased by the brothers. Although Mortimer and Raymond Sackler did not possess the incredible drive and creativity of their older brother Arthur, nevertheless they were shrewd businessmen in their own right.
However, an event occurred that precipitated a bitter, permanent split between Arthur Sackler and his younger brothers.
The Rift Between the Sackler Brothers:
In September 1971, Bill Frohlich died suddenly from a brain tumor, at the age of 58. Upon his death, the existence of the ‘tontine’ was made public. One of Frohlich’s major business assets was his ownership of a Manhattan agency called IMS. That company collected sales data for pharmaceuticals, and information on the drugs that doctors were prescribing to their patients. That information was then sold to pharmaceutical companies. Under the terms of the four-way agreement between Frohlich and the three Sackler brothers, ownership of IMS should have then reverted to the surviving three Sacklers.
However, attorneys for Mortimer and Raymond Sackler argued that Arthur Sackler should not receive any money from IMS, on the grounds that it would have been a conflict of interest for Arthur to have an ownership in IMS while he was the principal owner of the McAdams advertising agency. In addition, they argued that because IMS had offices in several other countries, it was really an international firm and not an American company. Therefore, they claimed that the IMS assets should fall under the international agreement, of which Arthur was not a signatory.
Eventually, IMS went public and some of its assets were divided up. Bill Frohlich’s heirs received $6.25 million, Mortimer and Raymond received a total of $37 million, and Arthur Sackler received nothing. This caused a permanent rift between Arthur Sackler and his two younger brothers. Arthur maintained that IMS was his idea in the first place, that he had set up Bill Frohlich as the president of that firm, and that he had graciously included his younger brothers in the “Musketeers” agreement. So Arthur felt that he had been badly wronged by being cut out of the proceeds from IMS.
Although their ownership of some companies such as IMS was terminated after Bill Frohlich’s death, the three Sackler brothers continued to share ownership in several companies. More legal disputes would arise after the death of Arthur Sackler; we will review this in the following section.
Arthur Sackler was a man of apparently boundless energy and creativity. He was arguably the most important individual in the field of medical advertising. Arthur’s personal characteristics were extremely important in the pharmaceutical advertising “playbook” that he created, particularly in the spectacularly successful advertising campaigns that he created for Librium and Valium. As we will see, his extended family was keenly aware of Arthur’s methods; they would follow closely the “Arthur Sackler playbook” in the rollout of their time-release oxycodone drug, OxyContin.
Debunking Denial 