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Dear Inklings,

This morning, some big news. “Purdue Pharma, the company that makes OxyContin, the powerful prescription painkiller that experts say helped touch off an opioid epidemic, will plead guilty to three federal criminal charges as part of a settlement of more than $8 billion,” the Associated Press reports. Importantly, the agreement does not release any members of the billionaire Sackler family from criminal responsibility.

It is a historic moment, and yet only a step toward justice for one of the great cruelties of modern American life. It was a cruelty enabled at every turn by philanthropy, and so today I’m sharing a (lightly edited) excerpt from “Winners Take All.” It’s about how the Sacklers and Purdue used generosity as a smokescreen to distract from the perpetration of injustice. Philanthropy as the opioid of the people.

Generosity is not a substitute for justice

The Sacklers are one of the country’s richest families. They were Andrew Carnegie’s old gospel incarnate: Give and give, honorably, thoughtfully, abundantly, and expect in return that questions will not be asked about the money’s origins and the system that let it be made.

The Sackler brothers—Elizabeth’s father, Arthur; Raymond; and Mortimer—were doctors and cofounders of a pharmaceutical company that would come to be called Purdue Pharma. The brothers made large gifts to the Metropolitan Museum of Art (which opened a Sackler wing as a result), the Guggenheim, and the American Museum of Natural History in New York; the Smithsonian Institution’s Asian art museum in Washington, D.C., which boasted “some of the most important ancient Chinese jades and bronzes in the world”; the Tate Gallery and Royal College of Art in London; the Louvre in Paris; the Jewish Museum in Berlin; Columbia, Oxford, Edinburgh, Glasgow, and Salzburg universities; and the medical school at Tel Aviv University.

The brothers gave not only in their personal capacity; their company was also admirably generous to the communities in which it operated. It offered grants to local groups to “encourage the healthy development of youth by reducing high-risk behaviors, such as substance abuse.” It supported organizations that “improve quality of life at a national level and in our own communities.” It funded education programs to “help medical professionals recognize and reduce medication abuse.” In the shadow of its headquarters in Connecticut, it funded the Stamford Boys & Girls Club, a provider of services to the homeless, a library, the Stamford Palace Theatre, the Connecticut Ballet, the Stamford Symphony, the Stamford Chamber of Commerce, the Business Council of Fairfield County, the Stamford Museum and Nature Center, the Maritime Aquarium, United Way, and Making Strides Against Breast Cancer.

In the hubs of power and influence in America and around the world, it was difficult to avoid the generous legacy of the Sacklers. But one could ask whether the givers were obliged not only to contribute to solutions but also to answer about their role in causing the problems.

In business, the Sacklers had engaged in practices that at first raised eyebrows and eventually summoned serious legal problems. Arthur Sackler was, according to the New York Times, “widely given credit (some would say blame) for creating many of the drug industry’s more aggressive marketing techniques—for example, holding conferences for doctors in which attendees learn about the efficacy of the sponsoring company’s drugs.” That legacy of aggressive drug marketing affected the promotion of many different medicines, but it was particularly consequential for Purdue Pharma and its affiliated companies, and for American society, in the case of a painkiller called OxyContin, which it began to sell in 1996. OxyContin is a forceful narcotic that provides up to twelve hours of respite from serious pain. At first it was marketed as a breakthrough, with a time-release formulation that made it less likely to foster addiction and abuse.

“That claim,” the Times reports, “became the linchpin of the most aggressive marketing campaign ever undertaken by a pharmaceutical company for a narcotic painkiller.” In addition to the wining and dining at conferences, the marketers of OxyContin, including Purdue’s partner Abbott Laboratories, were ingenious in their pursuit of doctors—including in the case of an orthopedic surgeon who wouldn’t give the drug reps his time, until they discovered his weakness, according to STAT, a medical publication. “We were told by his nurses and office staff that the best way to capture his attention and develop our relationship was through junk food,” the drug reps noted in a memo disclosed by STAT. The reps were swift to act on the advice. An Abbott rep showed up the following week, according to STAT, bearing a box of donuts and other treats. The sweets had been specially arrayed to spell the word “OxyContin.” This time, the reps got the ear of the doctor. “Every week after that, the Abbott sales personnel visited the doctor to ask him to switch at least three patients to OxyContin from other painkillers,” STAT reported.

Purdue also pursued a strategy of promoting OxyContin to general practitioners, who tended to have the disadvantage (or advantage, depending on your viewpoint) of less training than specialists such as orthopedic surgeons in treating serious pain and in detecting signs of painkiller abuse by patients. There are also, of course, many more general practitioners than there are such specialists. This huge marketing blitz for OxyContin took Purdue from being a small drug maker in the mid-1990s to earning nearly $3 billion in sales in 2001. Four-fifths of that was from OxyContin.

Oxy, as it came to be called, was a powerful new weapon against pain, but it also swiftly became a widely abused street drug. It was meant to be swallowed, which allowed for the extended release. But, the Times wrote, “both experienced drug abusers and novices, including teenagers, soon discovered that chewing an OxyContin tablet or crushing one and then snorting the powder or injecting it with a needle produced a high as powerful as heroin.” And so OxyContin began to be implicated in a growing number of overdoses and deaths, concentrated in rural areas down on their luck. These deaths around the turn of the millennium turned out to be early signs of what years later would come to be called a national “opioid epidemic.” As the New Yorker reports, “though many fatal overdoses have resulted from opioids other than OxyContin, the crisis was initially precipitated by a shift in the culture of prescribing—a shift carefully engineered by Purdue.” Eventually, the Centers for Disease Control and Prevention would report that overdose deaths from prescription opioids quadrupled between 1999 and 2014, claiming fourteen thousand lives in that last year. That same year, nearly two million Americans “abused or were dependent on prescription opioids,” and a quarter of patients who used the drugs for noncancer purposes battled addiction. The opioids were sending more than a thousand people a day to emergency rooms. And in online forums, people traded notes about the best ways to get the best highs without killing themselves:

RE: CHEW OR SWALLOW WHOLE?

just keep in mind your tolerance will grow very very quickly!!! I ate 2 x 80;’s today since 10am and snorted 1 as of 10pm. Thats with 3 yrs experience and I suffer from 2 major

conditions that require pain treatment, but 2.5 or 2.25 could do it. I let loose on weekends. and it also varies with how much I am active. Walking, etc . . .

Be careful. I started with 4 x 20mg per day. . . . . . and now @ 300mg / Day.

You dont wanna go through withdrawals if you run out man. if you could have been with me December 24th last year I was out 1 week early at this level and had to suffer bad. You dont wanna know.

Sometimes no one sees a massive social problem like this coming. This was not one of those times. In 2001, as sales of OxyContin and other opioids soared, officials at the state employee health plan in West Virginia noticed something strange. As the insurer for state employees, it received paperwork when they died, including the coroner’s account of the cause of death. Officials at the insurer took note of a rising number of deaths attributed to something called oxycodone, the active ingredient in OxyContin, according to STAT. The officials were familiar with the drug, because prescriptions for it were exploding among their clients, who ingested $11,000 worth of it in 1996 and $2 million worth in 2002.

The officials were quick to speak up. They pushed for regulations that would require doctors to secure prior authorization before prescribing OxyContin, which was intended to confine usage of the drug to people who genuinely needed it and to keep it away from known addicts and others with a record of abusing it. But these efforts met furious resistance from Purdue Pharma. STAT reported that beating back any attempt to limit OxyContin prescriptions became a “top priority” for Purdue in 2001. A memo obtained by that news outlet, describing the annual goals of the company’s West Virginia operation, found “Stop any preauthorization efforts for OxyContin” prominent among them. Another memo mentioned a meeting with officials in West Virginia to “interrupt” any efforts on their part to slow the prescription of OxyContin.

As a former Purdue official explained to STAT, “We like to keep prior authorization off of any drug.” The official was casting these efforts as flowing from a generic aversion to regulation. Purdue found a clever workaround, using third-party companies known as pharmacy benefits managers to ensure that West Virginians could receive OxyContin without prior authorization. It made an arrangement to pay the benefits managers a “rebate” if they prescribed the drug without that additional safeguard.

Publicly, Purdue worked to project an image in keeping with its charitable spirit and that of its owners—that it existed to help people and was as keen as the state to prevent abuse or harm. Still, according to motions filed by the state’s lawyers:

Contrary to the picture of helpfulness and cooperation Purdue attempts to paint, Purdue’s employees were actively and secretly trying to prevent West Virginia from imposing any control on the sale of OxyContin.

McDowell County, West Virginia, turned out to be “a proverbial canary in a coal mine when it came to the emerging national opioid crisis,” STAT noted. Back in 2001, when officials at the insurer first spoke up, the state as a whole was still at 6 deaths per 100,000 residents from opioid overdoses. McDowell was already at 38 per 100,000, however, and its fate foreshadowed West Virginia’s, which would see its death rate more than triple in the ensuing decade, giving it the country’s highest rate of deaths from overdoses and of painkiller prescriptions in general. Many of those deaths might have been prevented if state officials had not faced the opposition they had to regulating OxyContin prescriptions. The McDowell sheriff, Martin West, said to visiting reporters, “Listen to the scanner here every night. It’s first responders out every night going up and down hollers for an overdose. It’s pitiful what is going on.”

Meanwhile, as other public servants around the country began to worry about the drug’s propensity for addiction and abuse, Purdue pushed back, according to the Times, “claiming that the drug’s long-acting quality made it less likely to be abused than traditional narcotics.” The U.S. Department of Justice disagreed: “OxyContin was not what Purdue claimed it was,” in the words of John Brownlee, who was then the U.S. attorney in Roanoke, Virginia. “Purdue’s assertions that OxyContin was less addictive and less subject to abuse and diversion were false—and the company knew its claims were false. Purdue’s misrepresentations contributed to a serious national problem in terms of abuse of this prescription drug.” The drug’s fraudulent promotion, he added, had “a devastating effect on many communities throughout Virginia and the United States.” Brownlee brought charges against Purdue, which in 2007 agreed to settle. It acknowledged that it had marketed OxyContin “with the intent to defraud or mislead,” and it agreed to pay $635 million in fines and other outlays.

It was one of the largest fines ever paid in such a case, but only an inconvenience when compared to how lucrative OxyContin was becoming. In 2015 Forbes declared the Sackler family the “richest newcomer” to its annual list of wealthy families, with a net worth of $14 billion. Noting that the family had edged out “storied families like the Busches, Mellons and Rockefellers,” it asked, “How did the Sacklers build the 16th-largest fortune in the country? The short answer: making the most popular and controversial opioid of the 21st century—OxyContin.”

Another answer to that question might be: by thwarting the guardians of the public good every time they tried to protect citizens. It was later reported that Brownlee had received an unusual phone call the night before securing Purdue’s guilty plea. A senior Justice Department official, Michael Elston, had called Brownlee on his cell phone and “urged him to slow down,” according to the Washington Post. Brownlee rebuffed his superior. “Eight days later,” the Post said, “his name appeared on a list compiled by Elston of prosecutors that officials had suggested be fired.” It was part of a larger attempted purge of prosecutors by the administration of George W. Bush. Brownlee kept his job; Elston lost his amid the controversy of the list’s becoming public. And what had occasioned the phone call? According to Elston, his boss, a deputy attorney general named Paul McNulty, had asked him to place the call to Brownlee after receiving a request for more time from a defense lawyer representing a Purdue executive.

Despite the easily available knowledge about Oxy and the Sacklers, MarketWorld embraced the family’s do-gooding and kept mum about the harm. The most common single-word descriptor for members of the family became “philanthropist.”

Generosity is not a substitute for justice, but here, as so often in MarketWorld, it was allowed to stand in. The institutions that benefited from the Sacklers’ largesse have shown little interest in demanding that they atone for any role they might have played in fomenting a national crisis. The generosity tended to be in places where influential people gathered, whereas the injustice tended to happen out of view, in places like McDowell County, whose storytelling apparatus had little chance of competing with a headline about a gift to the Metropolitan Museum of Art. The generosity was in the millions; the injustice had helped to build a $14 billion fortune. According to the New Yorker, “two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids” since 1999.

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Photo: David L. Ryan/Getty