Barry Blackwell´s Introduction to Patrick Radden Keefe´s Empire of Pain


Peter R. Martin’s comment


       Barry Blackwell’s introduction to Empire of Pain: The Secret History of the Sackler Dynasty (Keefe 2021) offers justified praise for both the author, Patrick Radden Keefe, and the epic tale he has pennedThis well-researched history of how the Sackler family dynasty conspired to influence mid-20th century medicine in the United States is interesting and compelling reading, particularly for physicians who must now recognize the Sackler touch on their daily clinical decision-making. 

       Accordingly, the book is very much à propos to many of the issues discussed over the years on the International Network for History of Neuropsychopharmacology (INHN) website.  INHN readers regularly review postings on the historical perspective of the development of medications for treatment of neuropsychiatric disorders; rationalizing pharmacotherapy through understanding of nosology and pathophysiology; the language employed to describe and communicate about these disorders; the role and optimal design of clinical trials for demonstrating the efficacies of these medications; and historical insights about the protagonists who moved the field of neuropsychopharmacology to where it now stands.  However, two issues seem central to the Empire of Pain – the ethics of neuropsychopharmacology practice and the risk of addiction with ill-chosen treatments. 

       It is testament to the stealthy influence of the Sackler dynasty on medicine that we have read precious little about them on the INHN website until the release of this book.  I am uncertain whether this is due to their skillfully clandestine stratagems to amass unimaginable wealth and influence over the pharmaceutical industry at the expense of patients genuinely suffering from the protean manifestations of anxiety and insomnia (benzodiazepines) or pain (high potency opioids),  or that the medical profession and government regulatory agencies chose to look the other way because the talented first generation of Sacklers intuited what physicians and their patients really wanted and were enormously generous philanthropists to the most renowned public and private institutions of learning and the arts. 

       At one time or another for more than half a century, the Sackler dynasty was instrumental in developing medical advertising as still practiced today via medical detailing by attractive and persuasive representatives with extravagant expense accounts (“free” lunches and samples of their wares); speakers bureaus enlisting paid practitioners willing for “honoraria” to proselytize their peer physicians to prescribe specific medications; and contracting medical thought leaders (also called “key opinion leaders” in advertising – KOLs) using disproportionate honoraria and paid junkets to lovely resorts to influence their clinical practice or to familiarize them with the multicenter clinical trials for which they would serve as “independent” investigators. 

       After reading the Empire of Pain, I came to understand that while the Sacklers may have recently faced a reckoning for their role in the ever-expanding opioid “epidemic” of the last 15 years, their influence on the treatment of chronic pain with opioids was only a small part of their many “contributions” to medicine.    

       The Sacklers were successful, indeed, in creating an almost limitless market for their wares based on the promise to alleviate the triumvirate of human suffering – anxiety, insomnia and pain!  First, they helped other pharmaceutical companies create sales for benzodiazepines using then novel advertising strategies.  Eventually, they expanded from marketing to manufacturing and distribution through their flagship company Purdue Pharma, all the while maintaining their fingers on the pulse of the populace and making mid-course corrections as problems with the opioid crisis came to the fore.  Along with the U.S. population, they gamed the Food and Drug Administration (FDA) through consultancies, honoraria and offers of employment subsequent to retirement from government positions. 

       They became experts in “marketing nosology,” coining the term “pseudo-addiction,” meaning a patient with pain could be prescribed high doses of opioids and not develop addiction.  Consequently, they contended that the tremendously profitable sales of morphine and oxycodone for the slightest indication of pain for minor causes had absolutely nothing to do with the rapidly growing opioid epidemic as only those prone to addiction were at risk.  In fact, to obviate any perceived danger of their wares they created new formulations of morphine and oxycodone, touted as being “tamper-proof” with diminished rates of opioid absorption and therefore, “addiction-proof.” 

       All along, they strove to make the Sackler name great as admonished to do so by the family patriarch Isaac Sackler, who taught them in their youth that reputation was much more important than one’s fortune because it can never be regained!  Major educational, healthcare and arts institutions were bequeathed with generous monetary and other gifts in return for naming rights.  Nevertheless, there were plenty of funds left over for lavish purchases of their own and lifestyles of opulence. 

       To be human is to strive and suffer and learn from the experience while continuing to strive.  These are motivating forces that keep us moving forward and succeed in our undertakings. To lose these motivations by dullness from pharmacological intervention is to remove our humanity.  What captivated me in this book is how skillfully the Sacklers understood and marketed solutions to Humankind’s wants and needs via the benzodiazepines and opioids.  They well-understood and exploited the post-war generation’s mistaken expectation that the discoveries of neuroscience and medicine would lead to pharmaceuticals that could ensure everyone’s right to be free of any pain or anxiety.  

       This viewpoint, characterized by entitlement, was not shared by their parents, a generation that struggled through the Great Depression and the Second World War II (Brokaw 1998).  Although the dystopic novel Brave New World that describes how constant consumption of a soothing and happiness-inducing drug called Soma to suppress unwelcome emotions like anxiety and pain (Huxley 1932) was required reading in the 1960s, the post-war generation did not believe that anxiety and pain were part of the human condition and that abolishing them at will might may not be desirable. 

       In fact, human emotions and sensations guide and protect the organism through life and can offer evolutionary advantage.  The notion that not all is hopeless and one must carry on despite the travails of life have been described in literature for centuries.  The example that inexplicably sprung to my mind was a play I read as a teenager (about the time I also read Brave New World) written by the Hungarian aristocrat Imre Madách (1823–1864) that describes in 15 scenes the interactions of Adam, Eve and Lucifer (refereed by God) through human history from the Garden of Eden far into an imagined future (Madách 1963).  Adam perceives in dream sequences tremendous victories of humanity against all forms of adversity until in the last scene Lucifer has finally convinced him that the future is hopeless.  The apocryphal last statement from God in the play was memorable: “Man, I have spoken: strive on, trust, have faith!”  This statement indicates to me that not all problems are immediately reparable, but we must do our best to manage – among them chronic symptoms as anxiety and pain.  Current recommendations of lifestyle changes and psychosocial interventions offer significant advantages over opioids and benzodiazepines for treatment of chronic pain, anxiety and insomnia because of worse outcomes generally and the likelihood of addiction (Martin et al. 2007). 



Brokaw T. The greatest generation. Random House; 1998.

Huxley A. Brave new world. Garden City, N.Y: Doubleday, Doran & Co.; 1932.

Keefe PR. Empire of Pain.  The secret history of the Sackler dynasty. New York: Doubleday; 2021.

Madách I. The tragedy of man; a dramatic poem in fifteen scenes by Imre Madách; Budapest: Corvina; 1963.

Martin PR, Weinberg BA, Bealer BK. Healing Addiction: An Integrated Pharmacopsychosocial Approach to Treatment. Hoboken, New Jersey: John Wiley & Sons, Inc.; 2007.


December 16, 2021