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Peter Attia MD186 - The Opioid Crisis with Patrick Radden Keefe
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CHAPTERS
- 0:02 – 3:25
How Patrick Came to the Opioid Story
Patrick Radden Keefe explains his long interest in drugs, from cannabis legalization to Mexican cartels. A surge in Mexican heroin led him to the opioid crisis, then to Purdue Pharma and the Sackler family.
- •Earlier pieces on cannabis legalization in Washington State and the Sinaloa cartel
- •A post-2010 surge in Mexican heroin was the riddle that started the inquiry
- •The inquiry moved from the illicit trade to the FDA-regulated trade with OxyContin
- •Discovering Purdue was owned by the philanthropic Sackler family
- 3:25 – 9:49
Mapping the Actors and Why Focus on Purdue
Peter Attia lays out the chain of actors in the crisis: producers, distributors, the FDA and DEA, policymakers, providers and patients. Keefe gives the scale of the crisis and explains why he chose Purdue and the Sacklers, arguing OxyContin was the tip of the spear.
- •Attia's chain: pharma companies, distributors, FDA/DEA, policymakers, providers, patients
- •At least half a million overdose deaths since the late 1990s and two million-plus with opioid use disorder
- •The crisis is now largely heroin and fentanyl, which the Sacklers point to
- •OxyContin changed prescribing habits and built a market that migrated to illicit supply
- 9:49 – 17:06
The Sackler Brothers: Immigrant Roots and Psychiatry
Keefe describes the three Sackler brothers, children of immigrants in Brooklyn, raised to value education and medicine. Arthur's early advertising hustle and the brothers' time at Creedmoor psychiatric hospital pushed them toward a chemical view of mental illness and into commerce.
- •Parents were immigrants who spoke Yiddish and prized education and meritocracy
- •Arthur's early start in advertising at Erasmus Hall High School
- •Brothers trained as psychiatrists at the vast Creedmoor asylum, using electroshock
- •Thorazine and the postwar pharma boom shaped their outlook
- 17:06 – 24:05
Purdue Frederick and the Family Business
Arthur bought the small patent medicine company Purdue Frederick and gave it to his brothers while he made a fortune marketing Librium and Valium. The brothers ran a modest firm built on products like Betadine and Senokot. Keefe and Attia discuss why it stayed private and how that shaped later events.
- •Purdue Frederick began as a 19th-century patent medicine company, bought by Arthur in 1952
- •Arthur's Librium and Valium marketing and his uncapped bonus scheme
- •Brothers ran cash-crop over-the-counter products like Betadine and Senokot
- •Keefe speculates a public company would have responded differently to the 2007 guilty plea
- 24:05 – 34:24
From MS Contin to the Idea of OxyContin
MS Contin, a continuous-release morphine for cancer pain, was a success amid a movement to treat pain more aggressively. When its patent neared expiry, Purdue chose oxycodone for a bigger market, and emails show executives deciding not to correct doctors' belief that it was weaker than morphine.
- •MS Contin's coating regulated morphine release and earned hundreds of millions a year
- •Patent life drives much of Purdue's behavior, including the later pediatric indication
- •Kathe Sackler suggested oxycodone to Richard Sackler
- •Focus groups showed doctors saw oxycodone as weaker, and executives chose not to correct that to protect the market
- 34:24 – 46:22
The FDA Approval and Curtis Wright
Keefe explains the unusual FDA approval of OxyContin, including the close relationship with FDA reviewer Curtis Wright. He recounts the lost emails and the unattributed package-insert claim, and discusses what he calls soft corruption and the revolving door.
- •The package insert is a key marketing document, and no tests of addictiveness or abuse liability were done
- •Purdue staff spent three days helping Wright write his reviews, and Wright later joined Purdue at triple his salary
- •FDA said Wright's emails were lost or destroyed after Keefe sued
- •The claim that the Contin seal is believed to reduce abuse liability had no scientific basis and no one admits writing it
- 46:22 – 54:36
Early Warnings and Purdue's Denials
After the 1996 launch, Purdue executives testified they had no inkling of problems until 2000. Keefe says emails and sales rep reports show they knew by 1997, and describes the 'whale' prescribers and the company's spin on abusers.
- •Executives including Goldenheim claimed four blissful years without knowing of problems
- •Internal emails discussed abuse, robbed pharmacies and street value, and warned against chatting on email
- •About 700 sales reps were the 'canaries in the coal mine', as in the Steve May story
- •Purdue blamed abusers, and the Sacklers still call iatrogenic addiction vanishingly rare
- 54:36 – 1:06:35
Paths to Addiction and the Reformulation
Attia proposes three paths by which patients encountered OxyContin, and Keefe says the split can't be known. They discuss the crushable pill, the 2010 reformulation tied to patent expiry, and the finding that 80 mg sales fell 25%, suggesting the black market helped pay the bills.
- •Three paths: legitimate prescription, sham doctors, and illicit acquisition
- •The Contin seal could be defeated by crushing, and a bottle warning acted as an inadvertent how-to
- •The 2010 reformulation extended the patent and Purdue then called the old version unsafe
- •80 mg sales fell 25% after reformulation, and UnitedHealth cited hundreds of thousands diagnosed with OUD after Purdue opioid prescriptions
- 1:06:35 – 1:18:23
Peter's Personal Experience with OxyContin
Peter Attia recounts a back injury in medical school, a botched surgery and an OxyContin prescription that climbed to nearly 400 mg a day. He describes quitting cold turkey, the withdrawal, and the pain care that helped him. Keefe reflects on how the story reflects the doctor, titration messaging and lack of off-ramping.
- •Prescribed 20 mg twice daily, he reached almost 400 mg a day within four months, all from a legitimate surgeon
- •He realized he could not separate pain relief from the high or from emotional pain
- •Stopping cold turkey brought three miserable weeks, and he credits biological luck, not willpower
- •Keefe notes Purdue's slogan of 'start with and stay with' and doctors who learned to on-ramp but not off-ramp
- 1:18:23 – 1:30:19
Pain Training, Time Pressure and the Fifth Vital Sign
Attia describes the pain care that helped him and how little surgical residents were taught about pain management. Keefe argues structural pressures such as time and money let Purdue snow the medical establishment, and discusses industry influence on the AMA and the fifth vital sign.
- •Attia's recovery used injections, Neurontin, Vioxx and physical therapy
- •Residents were taught almost nothing about pain, and an attending refused a five-minute nerve block
- •Keefe says doctors felt duped by a drug pitched as having no dosage ceiling
- •The fifth vital sign sounds like a marketing slogan and is subjective, with industry money underwriting education
- 1:30:19 – 1:39:48
Facilitators, Revolving Doors and Lobbying
Attia raises DEA official Lyndon Barber and senators who took small sums. Keefe describes an ecosystem of former prosecutors, regulators and lawyers who enabled Purdue, a strategy of choosing well-connected messengers, and the lobbying that got through the bill H.R.4709 and blunted state bills.
- •Former DEA, FDA and prosecutor figures went to work for industry and the Sacklers
- •Mary Jo White and Rudy Giuliani were used to go over prosecutors' heads
- •Attia notes the bipartisan nature of the corruption and the quiet passage of H.R.4709
- •Opioid makers outspent the gun lobby on lobbying and neutered state-level bills
- 1:39:48 – 1:42:46
The 2007 Plea and the Lack of Accountability
Keefe describes the Western District of Virginia investigation that sought felony charges against three executives to flip them on the Sacklers. Purdue's lawyers got Justice Department leaders to take felonies off the table, resulting in a $600 million fine and misdemeanor pleas.
- •Prosecutors investigated Purdue for five years and subpoenaed millions of documents
- •Giuliani and White lobbied the Bush Justice Department to drop felony charges
- •Fisher and McNulty each point at the other over the decision
- •The company paid $600 million and carried on marketing without slowing
- 1:42:46 – 1:50:12
Bankruptcy and the Non-Consensual Third-Party Release
Keefe explains how the Sacklers withdrew over $10 billion from Purdue, pushed it into bankruptcy and sought a permanent release from litigation in the White Plains court. He expects the $4.5 billion deal to be approved because many states need the money.
- •Purdue pleaded guilty again in 2020 for conduct dating back about ten years
- •Sacklers took more than $10 billion out of the company after 2007
- •Family wants a permanent non-consensual third-party release from Judge Drain
- •The $4.5 billion over nine years, back-loaded, leaves the Sacklers with roughly $11 billion
- 1:50:12 – 1:57:31
Deterrence, Jail Time and the Sacklers' Reputation
Attia asks about justice and deterrence. Keefe notes Insys executives went to jail while Purdue's didn't, argues that jail is the only real deterrent, and says the Sacklers' main cost will be reputational.
- •Purdue's 2020 plea named no individual executives, 'like a driverless car'
- •Insys was hard corruption where executives were jailed
- •Keefe says jail time is the only real deterrent
- •Attia compares the Sacklers' public stigma to O.J. Simpson's
- 1:57:31 – 2:04:13
The Sacklers' Disconnect from Reality
Keefe says the Sacklers are insulated by advisors and uniformly feel misunderstood, and he could find no apostate to talk to him. A WhatsApp log and Jacqueline Sackler's email show a sense of grievance and no introspection.
- •Name is toxic and coming down from institutions, but Keefe doubts the family feels shame
- •Billionaires surrounded by advisors risk delusion, a comparison Keefe made with Trump
- •People who urged an addiction foundation were sidelined or fired
- •Private chats and an email about private-school admissions show no self-reflection
- 2:04:13 – 2:21:59
Pain Patients, Regulation and the Path Forward
Keefe says prescribing has swung back and chronic pain patients fear losing access, but the problem was expanding the market and downplaying risks, not the drug's existence. They discuss the worsening crisis, resources, treatment and stigma, and the fragility of recovery.
- •Doctors prescribe less, and pain patients fear losing supply
- •Keefe is not a prohibitionist and locates the wrong in expanding the market and playing down risk
- •Calls for resources, treatment access, and less stigma around medically assisted treatment
- •COVID drained attention from a developing national strategy
- •Attia stresses that environment makes recovery hard one person at a time
