Empire of Pain is a 2021 work of narrative nonfiction about the origins of the social crisis around opioid use disorder by investigative journalist and writer Patrick Radden Keefe. A staff writer for The New Yorker, Radden Keefe is also the author of Say Nothing, an account of murder and sectarian violence in Northern Ireland, and The Snakehead, a 2009 narrative nonfiction work about Chinatown, immigration, and organized crime.

To explain how opioids became widely prescribed in the 21st century, Radden Keefe turns to the company that created OxyContin, Purdue Pharmaceuticals, and the family that created the company in its modern form, the Sacklers. Beginning with the humble origins of Arthur Sackler and his two brothers, Radden Keefe uncovers the family’s role in the field of modern medical advertising and the regulation of the pharmaceutical industry, before turning to the origin story of OxyContin. Radden Keefe also highlights the Sackler family’s role as art patrons and philanthropists and their tendency to obscure the source of their wealth—a secrecy that persisted until the controversy around OxyContin became too powerful to ignore due to increasing legal and media scrutiny.

Empire of Pain spans many genres. Part family drama, part legal and medical history, it argues that the story of the Sacklers is the story of American institutions. Unambiguously beneficial legacies, such as the growth of antibiotics and the increasing availability of treatments for mental illness and chronic pain, are threatened when profit eclipses ethical and moral concerns and the wealthy are insulated from the consequences of their own actions. Ultimately, the book is a cautionary tale about good intentions diluted by greed, power, and self-delusion.

Please note: This guide includes descriptions of living with opioid use disorder, including overdoses, description of deaths by suicide, and suicide attempts.

Plot Summary

The work opens in medias res, with a legal deposition in a case that involves a corporation’s responsibility for many deaths. The defendants can afford expensive, highly qualified attorneys. Kathe Sackler, one of the deposed witnesses, defends the family’s product, OxyContin, and stresses that Purdue Pharmaceuticals began as a small family concern.

Flashing back, the book examines the life of the Sackler brothers, Arthur, Mortimer, and Raymond. The sons of Jewish immigrants, the Sackler brothers all became doctors. Arthur was particularly energetic and driven, with a strong interest in business as well as medicine. Arthur and his brothers became interested in psychiatry, seeking alternatives to invasive or punitive treatments like institutionalization and lobotomy. Their research helped the development of pharmaceutical treatments for schizophrenia.

Arthur Sackler’s great fortune and success, however, came from his medical advertising agency and his medical newspapers, where he helped clients like Pfizer and Roche promote antibiotics and tranquilizers. He insisted that advertising was a public service, though he frequently concealed his conflicts of interest, especially when promoting his psychiatric research. He and his clients insisted that any addiction attached to tranquilizer use was the responsibility of irresponsible patients, not advertising. In the 1960s, Sackler’s advertising practices came under investigation when it became clear that the FDA was effectively promoting specific products through close collaboration with him and his colleagues. Sackler successfully defended his sense of honor and ethics, insisting that government oversight was not necessary. He and his brothers originally collaborated closely, supported charitable causes, and he helped them purchase Purdue Pharmaceuticals.

Arthur and his brothers became devoted patrons of the arts, donating to museums as well as institutions of higher education. Arthur was a connoisseur of Chinese art, endowing his own private wing at the Metropolitan Museum of Art, while his brother Mortimer did similar work in London. Arthur Sackler died in 1987; the remainder of the book concerns Raymond and Mortimer and their descendants.

Raymond Sackler’s son, Richard, knew his career would be at the family business, and grew up accustomed to wealth and comfort. He decided Purdue should focus on pain management, a new field of study in the 1980s. The company first promoted opioids for cancer patients, palliative care that allowed terminally ill people to spend their final days at home. However, Richard Sackler wanted to expand the concept of pain management, and was interested in technical innovations that released opioids more slowly into the bloodstream, circumventing anxieties about addiction. OxyContin officially launched in 1996.

Like his uncle Arthur, Richard Sackler relied on a close relationship with the FDA. He relied on promotional material from the agency to tout OxyContin as not habit forming and long lasting, even as evidence to the contrary emerged. As early as 1999, patients reported developing use disorders due to the drug; there was also evidence of OxyContin’s increasing popularity as a recreational product, since snorting or injecting it circumvented the slow-release mechanism. Despite the fact that the company was aware some of its profits came from off-label use, Purdue’s aggressive marketing to regions with high numbers of workplace injuries continued largely unabated. Investigative journalists took an interest in the company’s aggressive sales tactics as early as 2001.

The company avoided legal liability for overdoses and deaths until a 2008 lawsuit from a federal court in Virginia. When investigators uncovered a systemic commitment to OxyContin overprescription, they faced pressure from the Department of Justice to drop the case. The Sacklers successfully neutralized the lawsuit by having some top executives plead guilty to misbranding.

In the years afterward, the Sacklers continually sought to extend their exclusive patent on the drug, developing a tamperproof pill which could not be injected. This created a new market for heroin, while opioid use disorder attracted increasing attention from press and state attorneys general. Radden Keefe notes that while Richard Sackler was a particularly abrasive personality, his entire family blamed the crisis on the poor choices of addicts, and not on their company’s tactics or aggressive advertising. They remained concerned with protecting their fortune and increasing future profits as much as possible.

Mortimer and Raymond continued to engage in philanthropy, as did their children, until 2016, when artist, photographer, and activist Nan Goldin, who had become internationally famous for her photography of the AIDS crisis, went public about her struggles with opioid use disorder and dedicated her life to removing their presence from the art world. Radden Keefe first wrote about the history of the Sackler family in 2017, much to their discomfiture, since he connected Arthur Sackler to the current crisis.

In tandem with this moral campaign, state attorneys general banded together to sue Purdue Pharmaceuticals, seeking damages to help ameliorate the public health crisis. Though the family avoided the loss of their personal fortune, partly by filing for bankruptcy and seeking redress from the Justice Department, their loss of social standing was more difficult to avoid. Massachusetts Attorney General Maura Healey insisted that the record of their malfeasance remain public and transparent, and Goldin and others successfully removed the Sackler name from many institutions, including Tufts University and the Guggenheim. By 2021, the family’s reputation as notable philanthropists was irrevocably tarnished.