186 - The Opioid Crisis with Patrick Radden Keefe

1. 0:00 – 0:10

   Intro

   1. PAPeter Attia0:00

      [upbeat music] Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Attia. [upbeat music] Hey,

2. 0:10 – 6:32

   Patrick’s investigation into distribution and use of drugs in our society

   1. PAPeter Attia0:10

      Patrick. Thank you so much for making time to sit down. I know you've, uh, done a number of these interviews and, uh, one of the things I always like to do is try to go places or at least deeper than maybe you've gone before. So we'll see if that can be accomplished. There's certainly no shortage of material here to, uh, to dive into. But I guess I kinda wanna start with, uh, a question that I, I know you've probably spoken about before, which is what, what drew you to this story? Because the depths that you've gone to to, to research your book have been, uh, you know, certainly at the, uh, the upper decile, I would suppose, of what an investigative journalist would do.

   2. PKPatrick Radden Keefe0:44

      Um, thanks. Uh, uh, it's great to be with you, and, and, um, yeah, happy to, happy to talk about how I came to this. I... I've always been interested in drugs, uh, as a subject. Um, the, the way in which drugs kind of fit into our society, uh, how we feel about them, which drugs are licit, which drugs are illicit. Um, I wrote a big piece a number of years ago a- about the legalization of cannabis in Washington State. I was just very interested in this idea that, you know, you have this existing industry, this pot industry that's been around for decades, and then with the stroke of a pen, you know, at midnight, it's legalized, and what does that look like? Uh, how do you turn it into a, a taxed and regulated economy? Um, and I had done a lot of writing on Mexican drug cartels. So I did, uh, a big piece, actually, before I was full-time at The New Yorker. I did a cover story for The New York Times Magazine back in 2012 about the Sinaloa drug cartel. Um, and to give you a sense of context, I mean, at the time, I had to explain to the editors of The New York Times Magazine who Chapo Guzmán was. He was not a household name at all. Um, and the idea there was I wanted to do sort of a, like a Harvard Business School case study of a cartel. I wanted to look at it as a, as a multibillion-dollar transnational commodities enterprise. And I was really interested in how they diversified and how vertically in- integrated they were, and one of the questions that kind of grew out of that research was, you saw at a certain point a surge in heroin. So they had different pro- I mean, Sinaloa, um, dealt in cocaine, marijuana, uh, heroin, and methamphetamine. But after 2010, you start seeing more Mexican heroin, huge volumes of it coming across the border in ways that it hadn't been before into the US. And that was kind of a riddle that I started with, was this, this question of, you know, why this sudden uptick in heroin? And the answer was the opioid crisis. Um, and so it was one of these funny things where I, I started out with an inquiry that was kind of solidly grounded in the realm of, uh, the illicit drug trade and found my way into the world of the FDA-regulated legal drug trade, uh, with OxyContin and Purdue Pharma, um, and sort of started looking into the origins of the opioid crisis and then discovered that this company, Purdue, was owned by the Sackler family, and that kind of blew my mind, the idea that this family that's quite well known for philanthropy had made such a huge fortune on this drug with such a controversial legacy. And so that, that was kind of the way in for me.

   3. PAPeter Attia3:25

      You know, I kind of drew on a piece of paper a long time ago when I was trying to get my mind around this how many actors there were, and, you know, it, the, the paper looked something like this, right? It started on the left, and it had producers. So the, the, I mean, and then this was all, I was talking about this not through the illicit chains.

   4. PKPatrick Radden Keefe3:45

      Mm-hmm.

   5. PAPeter Attia3:45

      Um, so you had sort of the pharma companies, of which Purdue would be sort of the champion of them. And then you have the distributors or the intermediaries, the McKessons and the Cardinals of the world. I, I actually knew a lot about McKesson through a previous life, so I was intimately familiar with, with what companies like McKesson did and how they were able to distribute products from the producers to the retail, the pharmacy, the CVSs of the world. So that became your third actor. Your fourth actor then became the, the FDA, um, in the approval process of a drug and then the DEA around enforcement. You could even put those two in a bucket. You then have the regulators that create, or the policymakers rather, that create the policies that allow these entities to exist. And then you have the providers, people that write the prescriptions for these things, and ultimately, you have the patients. So that's maybe a bit of an oversimplification, but it gives you a sense of just how complicated this web is.

   6. PKPatrick Radden Keefe4:38

      Mm.

   7. PAPeter Attia4:38

      Now, we're gonna spend a lot of time talking about one entity within one of those buckets. Um, so why do you think that that is a place for someone who's maybe listening to this podcast to get a pretty good sense of the magnitude of this problem? Because I don't think anybody could with a straight face say there isn't a problem, and, um, you'll put some numbers to what that means. But it's interesting that perhaps the study of Purdue Pharma and the Sacklers, more than any other single entity in that entire chain that I explained, could provide a greater context of what we're up against. Would, would you agree with that? I mean, I'm assuming you have a bias, [chuckles] otherwise you wouldn't have studied them so extensively.

   8. PKPatrick Radden Keefe5:20

      Yeah. I mean, I, it's interesting. It, it, I, it's, it's great that you lay it out with that much nuance 'cause that's the kind of nuance that often gets lost. Um, so there's two things I'd say. I mean, one is a kind of, a sort of observation that, that I would make as a writer and a journalist and somebody who writes books is, um, I go where my interests lead me. I, you know, I write stories that I think are, are interesting stories, interesting to me, that I think are important, that I think would be interesting to readers. Um, it's very, very often the case that I'll spend a lot of time on a, on something and, and the reaction that people have is, "Well, why did you pick this? Why didn't you write about this other thing?" You know? "I think that there's this other v- variable that's very important here." Um, and I, you know, I kind of, um- Instinctively resist those types of questions, right? Because on some level, I feel as though it's my prerogative as a writer to kind of pick the area that interests me and do it and hopefully do it well in a way that has some integrity. Um, but I make no claim to suggesting like this is the be all and end all. So in this case, if it's the opioid crisis, you know, there's, there would never be any suggestion that like, this is the only book you need to read on the opioid crisis.

3. 6:32 – 9:19

   The scale of of the opioid crisis

   1. PKPatrick Radden Keefe6:32

      Um, and, and to segue from that into the particulars here. So when we talk about the opioid crisis, we're talking about a, an incredibly complex public health crisis that unfolds over the course of a quarter of a century. You know, today the numbers are, are a little imprecise, but you know, you have at least a half a million people who've died from opioid overdoses since the mid to late 1990s. By some estimates, you have two plus million Americans today struggling with an opioid use disorder of one sort or another. And when we talk about opioids, that's actually a kind of pretty capacious category, right? So it's, it's, uh, you know, regulated drugs like OxyContin, but it's also, uh, fentanyl, you know, that, that, that comes in from China or, or Mexico. Um, uh, it's heroin. And in fact, when you talk about the, the death toll today, uh, I think the Sacklers certainly, um, uh, w- would be quick to say today people are dying in very large numbers from heroin and fentanyl overdoses, not from OxyContin or indeed, you know, from, from most, um, prescription painkillers. You know, this, this problem has kind of transitioned into an illicit drug problem. So why pick, uh, OxyContin? Why pick the Sacklers? In, in my view, you know, in part because it's an interesting story. I'm interested in the fact that this was a family. Family dynamics are interesting to me, um, in part because of the philanthropic legacy, because there's, um, this kind of disconnect, or there was until recent years, between the reputation that the family had and what I would argue is the reality of, of their business. But, but most importantly, because I think that this was a, OxyContin was sort of the, in the words of somebody who worked on the drug, was the tip of the spear. So I think it's, you know, it, it, this is a, the kind of nuance that often gets lost, right? But the, the, it, it, it can be possible to stipulate that today the opioid crisis is a heroin and fentanyl crisis, and also to keep in your mind the idea that absent OxyContin, we might not be where we are today. That, that it was the, the kind of first mover in terms of changing prescribing habits in the United States in a way that had really fundamental consequences and ultimately built up a market for these drugs, a market which eventually migrated to illicit sources of supply. So that, that would be the reason. I'm sure we can talk about it in, in more detail, but I think there's kind of a special role that Purdue and the Sacklers played, which is not for a second to suggest that there isn't blame with all those different buckets that you mentioned, because there absolutely is.

4. 9:19 – 17:05

   The Sackler brothers: family life, career in the pharmaceutical industry, and role in the current crisis

   1. PAPeter Attia9:19

      And, and I think y- you know, based on what I've read of your writing, it, you also seem very, um, very well informed about those other buckets. So I, I definitely want to make sure we touch on them, but there's no place to, to start like where we're going to start. So let, let's start with the three Sackler brothers. Um, take your, take your pick of who you want to begin with, Arthur, Raymond, Mortimer. Um, who, who were these guys? What got them interested in, in, in pharmaceuticals, um?

   2. PKPatrick Radden Keefe9:49

      Yeah, I mean, you have to start with Arthur. I think y- you've got these three brothers, um, who, they were the children of immigrants. Their parents had come over from Europe at the turn of the last century, settled in Brooklyn. Uh, they were Jewish. The parents didn't speak English really all that well initially. They spoke Yiddish in the home. Um, and they raised their kids to, um, to believe in a few things. I think, I think to believe in education, to believe in meritocracy. You know, there's this, I think, kind of wonderfully American, um, there are these kind of very American, like, mythical contours to the early parts of this story, right? Where there's a family that kind of came with nothing and, and had an ex- a hope and an expectation that within the span of one generation, they would build an empire and really kind of make their mark on the country and the world. And they were right. And so they raised these three brothers. Arthur later said that from the age of four, he knew he would be a doctor, um, with a sense that the, you know, you're all gonna grow up, you're gonna get educated, you're gonna become physicians. And there was a sense that there was kind of nothing as, um, prestigious and virtuous as being a doctor. Um, I think there was a real kind of, um, uh, veneration in this family for the role of the physician in society. And so the brothers grow up, but they also grow up, you know, a- against the backdrop of the Great Depression. There's a period where their father loses everything, and so, um, there was an expectation that, you know, you also have to go out there and hustle and make money and have jobs. And so all three brothers work multiple jobs and, um, you know, I'd, I'd say in the book of Arthur Sackler, it's like he, it, he, he's a guy, it's like he squeezed four or five lifetimes into one lifetime in terms of everything that he did. Um, and, um, they, they end up eventually in the pharmaceutical business, but the way they get there is through pharmaceutical advertising and marketing, and that actually starts back in high school. You know, when, when Arthur Sackler's in high school, he, he gets jobs on the, on the, um, on the student publications. He's at this huge high school, Erasmus Hall High School. It's something like six or seven thousand students, uh, in Brooklyn, in Flatbush. It's still there today. And, um, [lip smack] he gets jobs, you know, on the student magazine, the student newspaper, but he becomes the advertising manager. And if you think about it, you have 6,000 or 7,000 students that you can reach. That was a real job. Um, and so that's where the, the hustle starts with Arthur. And all three brothers end up training as psychiatrists, uh, practicing as psychiatrists, but they, they pretty quickly pivot into commerce.

   3. PAPeter Attia12:44

      [lip smack] So what were the types of drugs of that era that were really making a difference in their practice? Um, it seems that, um, you know, sedatives were, were potentially becoming of interest in that era.

   4. PKPatrick Radden Keefe13:03

      Yeah. I mean, you know, you have this kind of early, um, amazing moment where Arthur ... Th- there's this pattern that asserts itself with the brothers where Arthur goes and he does something, and then he kind of brings his brothers in with him. That starts in high school with him getting ... You know, he's got- got more jobs than he can handle, so he starts handing them off to the brothers. And he ends up at the Creedmoor Psychiatric Hospital, which is a, a huge asylum, a vast kind of industrial asylum in Queens, New York. Public state mental hospital.

   5. PAPeter Attia13:35

      With a staggering capacity, right? It's something like 6,000 beds. I- I mean, I ... When I read that-

   6. PKPatrick Radden Keefe13:39

      6,000 beds. Yeah

   7. PAPeter Attia13:39

      ... I thought, "That can't be possible."

   8. PKPatrick Radden Keefe13:41

      Yeah.

   9. PAPeter Attia13:41

      I don't know what that would look like, meaning I j- I literally can't picture the infrastructure-

   10. PKPatrick Radden Keefe13:45

       Physically

   11. PAPeter Attia13:46

       ... large enough to have 6,000 inpatient beds.

   12. PKPatrick Radden Keefe13:49

       Yeah. I mean, it was a vast facility, uh, but I, but I believe it was a, a facility designed for 4,000 beds. So, um, I mean, part of this is a reflection of the kind of, um ... [lip smack] You know, it's interesting 'cause in these years, right? Like, this is, this is pre-Thorazine. Um, y- y- it's, it's kind of the, the ... It's, like, the last, um, kind of maximalist phase of, um, of big state mental hospitals, right? Of people basically being warehoused for life in these facilities. Um, it's just prior to the deinstitutionalization that happens in, in the decades that follow. And so the brothers get there, and they're shocked by the conditions. Um, and also, if you think about it, I mean, Arthur in particular is, he was a Freudian. He trained as a Freudian, right? So, like, not a lot of talk therapy happening at a 6,000-bed hospital. Um, they were looking for, uh-

   13. PAPeter Attia14:42

       Were they still doing lobotomies and things like that?

   14. PKPatrick Radden Keefe14:44

       They were. I mean, in fact, lobotomies start up during this time. So it's a ... But it's a lot of electroshock-

   15. PAPeter Attia14:49

       Mm-hmm

   16. PKPatrick Radden Keefe14:49

       ... treatment, and then, and then lobotomies. And I should say, I mean, uh, you know, electroshock has its, has its defenders, um, even today. Uh, it, it, it, it obviously has, you know, it is very successful for some people in some circumstances. But the Sackler brothers are there, and they're administering it thousands of times, and I think it just became more and more demoralizing for them because they just felt as though, "We have to ... How can we as physicians not have, um, developed some more humane way of administering to our patients?" And so th- they develop, e- e- even at that point, this theory that a lot of the afflictions they're seeing are, you know, probably have some, some basis that is fundamentally chemical, and if that's the case, then there's probably some chemical solution. Um, and the brothers don't have anything to do with Thorazine, but when it comes along, uh, they see that, right? I mean, this is in some ways a kind of glimpse of the future that they had, that they had envisioned. Um, and, uh, m- it, it was, I think, generally speaking, an exciting time in the pharma business, right? 'Cause you have, you have penicillin, um, uh, which is a huge game changer in the Second World War, and then a lot of these, um, you know, these companies that today we think of as, like, big pharma, w- prior to the Second World War, they didn't really look like they do now. Um, they were producing chemicals, but they weren't really producing branded drugs in quite the same way. And then you just get this go-go period where they're all competing, and they're developing new antibiotics, and, um, they're coming out with new products every few weeks, and suddenly they need to differentiate themselves. And consumers are, you know, they're no longer, uh, going to the, the pharmacy and having the pharmacist mix whatever it is that their doctor has prescribed. They're going in and requesting drugs by their brand name. Um, and so it's, it's in that kind of exciting, I think quite idealistic whirlwind climate that the Sackler brothers

5. 17:05 – 27:15

   Purdue Pharma: origins, early years, and move towards pain management drugs

   1. PKPatrick Radden Keefe17:05

      come of age.

   2. PAPeter Attia17:06

      Where did Purdue Pharma come from? Was it a company that they founded? Was it something that they bought and later transformed?

   3. PKPatrick Radden Keefe17:13

      It was the latter. It had been, um, uh, their ... I- its origins date back to the 19th century. Uh, it was a little patent medicine company, um, based, funnily enough, uh, on Christopher Street in Greenwich Village, which is, like, the, uh, you know, you can go to the building that it once occupied. It's just funny that the, [chuckles] you know, the, um, the ... What had once been the, the, the sort of humble Purdue Frederick factory is, like, today somebody's $18 million townhouse.

   4. PAPeter Attia17:40

      Hmm.

   5. PKPatrick Radden Keefe17:40

      And in 1952, Arthur Sackler had already achieved a great deal of financial success, not in the drug business per se, but in, in pharmaceutical advertising. So he kind of, he really makes his name, um, by joining and then taking over a pharmaceutical advertising firm, and he's a, a genius for advertising drugs at this point where all these drug companies need to figure out ways to differentiate their products and reach doctors and persuade them to prescribe. And w- with some of the money he's made, Arthur purchases this company, Purdue Frederick, and he basically gives it to his brothers. So he remains a, um, a You know, he's a stakeholder in the company. He owns a, a third of it. Um, but he's a silent partner basically, and the brothers will run the company, and that, that's in starting in '52.

   6. PAPeter Attia18:37

      And what happens over the next 30 years?

   7. PKPatrick Radden Keefe18:40

      So they, y- y- you know, it's funny, Purdue Frederick was a very successful company. I mean, the brothers get rich, but they're getting rich in a, in a, in a way that is, um, I think that even Arthur would probably have sniffed at because Arthur, who, again, you know, he, he's, he's, um, he's one of the owners of the company, but not involved day-to-day. He's really focusing on the marketing of pharmaceuticals, and his big success is, I mean, he had many successes, but his biggest success, um, is that he designs the m- the marketing and advertising strategy for, um, the minor tranquilizer Librium, and then for Valium, both of which Roche develops. And, and Librium becomes the biggest selling drug in the history of the pharmaceutical industry, uh, and then it's surpassed only by Valium, and then for years, the two of them are in the top five drugs, uh, nationwide. And Arthur designed all the advertising and the marketing for that, and he, he devised this, um, interesting compensation scheme where basically he said, "I'm gonna get a, an escalating series of bonuses depending on how many pills you sell," and there's no ceiling. So he becomes vastly wealthy on the basis of these drugs. His brothers, meanwhile [laughs] , you know, what they're doing is less cutting edge. They basically license over-the-counter products and then sell them, and they were really smart about it. So they had a antiseptic solution, Betadine, which is still out there. Um, and they, you know, they got the rights to that just before the Vietnam War. It b- had kind of battlefield applications in Vietnam. Um, they had a, uh, a laxative, Senokot, very successful. These are these kind of cash crop products. They're very unglamorous, but they're staples, um, over-the-counter stuff, but year in, year out, they're very, very successful.

   8. PAPeter Attia20:35

      The irony, by the way, of the company that would create the opioid boom having a laxative, which is, of course, there [laughs] to address one of the most painful short-term consequences of opioid use, being constipation.

   9. PKPatrick Radden Keefe20:50

      Well, and the crazy thing is that they, eventually it gets to a point where the sales reps for Purdue would go out and, you know, they'd, they'd, they'd, they'd market the one with the other, right? It's, uh, they, um, [lips smack] uh, they would market them together. But the, um, but it's really only in the '80s that the company starts getting more, late '70s, early '80s, the company starts getting aggressive about really investing in R&D, um, and developing its own, um, prescription drugs. Uh, and it, it's at that point that they move into pain management.

   10. PAPeter Attia21:27

       Any inclination from your research why they decided to keep this company, uh, private as opposed to take it public like many of the large pharma companies?

   11. PKPatrick Radden Keefe21:35

       [lips smack] God, you know, I, I can only speculate. Um, but the, the Sacklers had a real sense, I think for a long time, that this was a kind of old world enterprise, that it was a family business. It was family-owned, physician-owned, they would always say. Um, there was a sense that they controlled it, and they thought of the people who worked for them as family. Um, you know, it's really only with the advent of OxyContin in the '90s that the, that it becomes this, you know, multi-billion dollar company. Up to that point, um, it was a pretty modest outfit. Um, the Sackler brothers themselves did really well. They were very wealthy. Um, but it was a kind of manageable family firm, and I, I, I think that there was, there was something to that. Um, [lips smack] I don't know. I don't know what it would've looked like if it went public. I do know that you've kind of put your finger on something there because I think when you, when you get into the later stages, kind of post the introduction of OxyContin, there's a lot of stuff that happens at the, in this story that would never happen in a public company.

   12. PAPeter Attia22:53

       Yeah, that's sort of my, that- that's the revisionist history in me, which is saying like, had they been a public company, how far would this have gone?

   13. PKPatrick Radden Keefe23:02

       Yeah, I mean, I don't mean to suggest that, I think in the early going, and we, we can sort of get into the, into the particulars, but there are these like hinge moments in this story. And so you have, um, you know, you've got all the stuff that happens prior to the introduction of OxyContin, and then you s- you start seeing things go wrong, and then they go more wrong, and it's like, well, how do you handle it when you see, how do you handle it when you start getting calls saying that the product that you sell is killing people? And, and I think that probably would've been a different response in a public company. Um, and then the, the really crazy thing is eventually, we're getting ahead of ourselves here, but eventually you get a, a guilty plea in a, in a federal criminal case in 2007. And I think in a public company, if you had that, um, I just think heads would've rolled. You'd have a total change of personnel, you know, big shakeup on the board. Um, and at a, at a privately held family company, what happened [laughs] was like nobody really got fired.

   14. PAPeter Attia24:02

       Pretty much nothing. Yeah.

   15. PKPatrick Radden Keefe24:03

       Yeah, yeah.

   16. PAPeter Attia24:05

       So talk a little bit about MS Contin as the precursor to OxyContin, and m- m- maybe the pharmacokinetics of it, but more importantly, what that transition was about.

   17. PKPatrick Radden Keefe24:17

       So, you know, in the, in the 1980s, um, you saw the beginning, I mean, actually dating back to the '70s, a, a, a kind of revisionist school of physicians who felt, in, in the UK and in the US and other parts of the world, who felt that, um, the medical establishment had been, um Not taking pain seriously enough as a problem, that, um, doctors weren't treating pain aggressively. They were treating it just, just merely as a symptom, not as a problem in and of itself. Um, that there wasn't enough medical education, uh, for physicians in terms of identifying pain and responding to it. Um, and kinda going along with this was, was a sense that, that many physicians had that, um, there was a resistance to, uh, prescribing opioids out of a fear of addiction, that, that, that, that doctors have been too stingy in prescribing opioids for pain, um, because of concerns about abuse and addiction. And it's in this context that MS Contin, this drug, is developed, and it's a cancer drug. It's a drug for cancer pain. Um, and it's basically just morphine. Uh, but the, the real innovation was the Contin part. So Contin, short for continuous, and it's, it's essentially this, the coating on the pill, and the idea is that this will regulate the flow of the drug into the bloodstream over the course of hours. Um, and so MS Contin was developed, uh, in the UK and then rolled out in the US, and it was, it was, you know, it was kind of a, a groundbreaking drug in its way. Very successful for the company. You know, it was ... I, I don't remember exactly what it was generating in terms of revenue at its height, but, you know, kind of $300 or $400 million a year, um, which was a lot for Purdue and, at the time. And, um, it was a big success. And, and I think the, the family was, was proud of it, and there was a sense that, um, you know, they were doing a good thing, uh, relieving terrible pain for people, uh, suffering from cancer, um, and, uh, and doing very well financially. And, and they, and so they were kind of in this world of, of, um, doctors who were thinking about pain and wanting to kind of reevaluate the way in which pain is treated. They were heroes. And you had this kind of interesting, and I don't think necessarily altogether cynical, confluence of interests, right, in which Purdue starts sponsoring academic conferences on the treatment of pain, and medical conferences, and seminars. And they're sort of out there with an obvious commercial interest, but also, um, I, I think a sense that, you know, we're part of a revolution here. We're gonna revolutionize the way in which pain is treated.

6. 27:15 – 46:21

   The development of OxyContin: its conception, marketing, and the controversy around the FDA approval process

   1. PAPeter Attia27:15

      So whose idea is OxyContin? I mean, in some sense, it's an obvious leap because if MS Contin is simply morphine sulfate formulated in a continuous fashion, there are other, um, narcotics out there. Percocet already existed. It was simply hydrocodone with, um, acetaminophen. Hydrocodone existed by itself in a non-time released format. So was there great innovation basically saying, "We're just gonna make a time release version of hydrocodone," just as it had been done with morphine? Was that effectively the aha moment?

   2. PKPatrick Radden Keefe27:52

      Y- yeah. I mean, what happens is that MS Contin is, um, something ... I mean, I should say, and this will be, this will be not a surprise to you, but, but to me coming from the outside, I, I was really startled. Um, I knew as a kind of objective analytical matter that, uh, that the life cycle of a patent [laughs] is very important to a drug company. I don't think I fully appreciated the degree to which it is the sun and the stars and, you know, it's everything. And, um, there were so many points in the course of my reporting for this story where there'd be some, some sort of mystery about motivation. There'd be some weird thing that they did, and I couldn't figure out why. And I would puzzle over it, and puzzle over it, and puzzle over it, and then it, it always turned out to be something having to do with a patent. You know, that the, um-

   3. PAPeter Attia28:38

      For example, the, the, the pediatric indication. [laughs]

   4. PKPatrick Radden Keefe28:42

      The pediatric indication. Very good example.

   5. PAPeter Attia28:43

      Yeah.

   6. PKPatrick Radden Keefe28:43

      Right. So the, um, where they, they, uh, applied to get the pe- ... Uh, at a point where OxyContin was hugely controversial already and causing all kinds of problems, they, they applied to, uh, for the, the pediatric indication for the drug. And I, I sort of couldn't figure out why, and, and they had all these explanations that turned out to not be true. And then it turned out it was because they thought they would get an additional six months of patent exclusivity, uh, if they got it. But the, um, but there's a bunch of cases like that. And in, in, in the case of MS Contin, the patent is running out at a certain point, and they realize that, um, it's gonna decimate their profits. And so they just start talking about, hey, what else could we put with, you know, the Contin system? Um, and some of the f- the family dynamics here are, are a little humorous, but there's, according to Kathe Sackler, who's one of the second generation Sacklers who's involved in the company and is a medical doctor, um, she has dinner with Richard Sackler, her cousin, um, and kind of rival within the company, uh, at a certain point. And she suggests, "What about oxycodone?" And according to her, Richard didn't know what oxycodone was, and she had to explain.

   7. PAPeter Attia29:57

      And oxycodone is stronger than both hydrocodone and morphine.

   8. PKPatrick Radden Keefe30:03

      It is. And the, and, well, the, I mean, part of what's interesting about, about oxycodone is that the, um, there's this amazing thing that happens basically where they, they make their decision, okay, we're gonna use oxycodone, so we'll, we'll develop OxyContin. And there are these conversations that happen, and they happen over email, and I have the emails, where these senior executives at the company, um, and Richard Sackler are talking about the market and, um, the idea that MS Contin was a drug for cancer pain, and the stigma associated with morphine, this, this notion that, you know If you're a, if you're a, a regular person, not a doctor, and your doctor tells you that your mother's going on morphine, that means your mother is gonna die. Um, and what they realized is that, uh, oxycodone didn't have those same associations, even though it's stronger than morphine. They did focus groups, and you have oxycodone in, in, uh, in Percocet and in Percodan, and that was the, the primary way in which physicians were encountering those drugs. And in, you know, when they're cut-

   9. PAPeter Attia31:15

      That's right. I mi- I misspoke earlier

   10. PKPatrick Radden Keefe31:16

       ... it's, it's not Percodan, yeah

   11. PAPeter Attia31:16

       I said it was hydrocodone. It's actually oxycodone.

   12. PKPatrick Radden Keefe31:18

       Yeah.

   13. PAPeter Attia31:18

       That's right.

   14. PKPatrick Radden Keefe31:19

       It's oxycodone.

   15. PAPeter Attia31:19

       Yeah, yeah.

   16. PKPatrick Radden Keefe31:20

       And when they're cut with aspirin or acetaminophen, it's, you know, it's a relatively small dose. There's only so much you can take. Um, so what they noticed in these focus groups is that physicians had a sort of a sense of, of oxycodone as more benign, you know, less threatening. There was less stigma, but also they, they saw it as weaker. And there are these incredible emails where they say, "Well, listen, there's only so many people who have cancer pain. You know, we did great with our cancer drug, but there's a much bigger market out there of people suffering not just from severe pain, but moderate pain, uh, chronic pain, back pain, sports injuries."

   17. PAPeter Attia31:58

       There's a funny, there's a funny cartoon you could envision here, which is another revisionist, which is imagine if instead they just decided to figure out a way to make more cancer patients.

   18. PKPatrick Radden Keefe32:07

       Right, right.

   19. PAPeter Attia32:07

       Well, how could we do to increase-

   20. PKPatrick Radden Keefe32:08

       Right. Exactly [laughs]

   21. PAPeter Attia32:08

       ... the number of people dying of cancer-

   22. PKPatrick Radden Keefe32:11

       Yeah. Yeah

   23. PAPeter Attia32:11

       ... to expand our market?

   24. PKPatrick Radden Keefe32:12

       Expand our market, right.

   25. PAPeter Attia32:12

       And then someone goes, "No, no, no, no, no, that's too hard. That's too hard. I got a better idea."

   26. PKPatrick Radden Keefe32:16

       Yeah.

   27. PAPeter Attia32:16

       "Let's just figure out a way to make everybody who doesn't have cancer takes this drug."

   28. PKPatrick Radden Keefe32:21

       Right, and in fact, to kind of, to, to sort of create the need, which is, you know, a big part of what the marketing ended up being. Yeah, I mean, the analogy that, that I come back to, you know, the fir- the first third of the book is devoted to Arthur Sackler and those earlier years and, and that was a, a, a very deliberate choice, even though Arthur Sackler dies in '87, before the introduction of OxyContin, 'cause I think there are all of these, um, I think there are all of these, um, [lips smack] uh, things that happen earlier that, that are kind of the seeds for what comes later. So the analogy I always think of is, is Thorazine, which the, the original Sackler brothers see. And, you know, Thorazine is a, um, is a, a major tranquilizer for people who are psychotic, and, um, it was very successful, you know, emptied out the, the, uh, asylums pretty quickly. I mean, there were other things that did as well, but it was a real game changer. But there's only so many people who are actually, y- you know, require that kind of heavy-duty solution. And then Arthur Sackler makes his fortune on the minor tranquilizers, where, you know, who among us doesn't feel a little stressed at the end of the day? Um, you know, who, who couldn't benefit from something to make them relax a little bit? Uh, and that was what turned Librium and Valium into these huge blockbusters. It's kind of a similar thing here, where, um, there's this sense that, you know, MS Contin is a drug for this subset of people who are in, experiencing terrible cancer pain. There's a much bigger community of people, um, who have, uh, moderate pain, but the weirdness of it is that they then take a drug that is stronger, not weaker, and market it that way. And you see these emails in which these executives say, "In our focus groups, doctors erroneously think that oxycodone is weaker than morphine. Let's not do anything to make them realize that they're wrong about the product that we're selling them, because if we did, it could constrain our market."

   29. PAPeter Attia34:24

       So they developed this new drug. What's unusual about the process by which it receives its FDA approval?

   30. PKPatrick Radden Keefe34:33

       [lips smack] Uh, a handful of things. Um, so they-
7. 46:21 – 54:35

   Early reports of OxyContin addiction and unintended consequences and how Purdue Pharma sidestepped responsibility

   1. PAPeter Attia46:22

      So what, is it '96 when MS Contin, uh, when, um, when OxyContin hits the, uh, hits the retail?

   2. PKPatrick Radden Keefe46:29

      Early '96, yeah.

   3. PAPeter Attia46:30

      So how long does it take before the unintended consequences, uh, 'cause there's really two unintended consequences here. Um, I guess the first is people who probably would be better served with another form of pain control are instead using this drug. That would be one unintended consequence. That's one that Purdue would not be against, 'cause that's simply more market share. And then there's the unintended consequence that everyone, including Purdue, would presumably not want, which is you start to kill your customers. Uh, you know, sort of the tobacco company problem, right? Like, to have an addictive product with no termination of use is wonderful if you just could figure out a way to keep the customer alive. So w- what are the, what are the canaries in the coal mine with respect to these problems and, and, and how are they handled?

   4. PKPatrick Radden Keefe47:29

      So, I mean, I think in some ways it's probably useful to start with what the official story was, um, which is that the drug's released in early '96, and according to sworn testimony by several senior executives at the company and by Richard Sackler, uh, they had no inkling that there was any kind of a major problem for four years. There were four blissful years where they got lots of letters from pain patients saying, you know, "You've given me my life back." Um, and there was no real sense at all that there was any kind of a problem. And it's only in, in early 2000 when the United States attorney for the state of Maine writes a letter to thousands of physicians saying, "This drug, OxyContin, is, is really dangerous, actually. It's killing people. People are overdosing. We've got a, we got a real problem here, and there's a crime problem associated with it."

   5. PAPeter Attia48:26

      And, and a little bit after this time, the chief medical officer, Paul Goldenheim, the chief medical officer of Purdue Pharma, is brought in front of Congress, right? And he's asked questions about this. What does he say?

   6. PKPatrick Radden Keefe48:38

      Same thing. He says, "We had no inkling that there was any kind of big problem until this hinge point," which is when this US attorney writes this letter in, uh, in 2000. Um, so, a- and interestingly, well, the other thing they say is that they say, "Oh, we read about it in the press." They say, "We, we, we read, we read about these problems in the press." And for me as a journalist, this was funny because the, um- You know, I've written about a lot of companies doing bad things and, and, uh, and y- y- you know, w- reporters like to take credit where they can, where they can get it. But generally speaking, if a company's doing a bad thing, you know, they don't find out about it because they read about it in your article. Um, you know, they usually know a long time before the rest of the world does. So, uh, there was something about their explanation that always seemed, um, just on its face seemed a little fishy to me. Uh, when I dug into it and got a bunch of, um, documentation, what I learned is that it was a, it was a lie. I mean, they, you know, they knew really early on, um, um-

   7. PAPeter Attia49:51

      How, how bold face a lie was that? Let's use, uh, Goldenheim as a specific example. So in 2000-

   8. PKPatrick Radden Keefe49:58

      Oh, I mean, there's-

   9. PAPeter Attia49:58

      ... he's, uh, he's giving sworn testimony that we- no clue this was going on. What do his emails from the late 1990s suggest?

   10. PKPatrick Radden Keefe50:07

       That they did. I mean, it's not just, you know, they, uh, you name it. There's, there's all kinds of back and forth about, um, these drugs. There's another sort of associated lie that they told, which is that there had never been a problem with MS Contin, um, which also is a lie, a lie that was told under oath, uh, when in fact there's all kinds of back and forth about that. But you've got very, very senior people, including Goldenheim, emailing about the fact that, um, there's an abuse problem, pharmacies are getting robbed. Uh, you know, um, there's the kind of, people talking about the street value of the drug. There was a, um, a, a kind of media advisory group that was brought in to do interviews with these senior officials. There are literally emails in which some of these senior officials who, who later claimed that, you know, nothing was said, wi- will be emailing about it and then they'll say, "Do you, should we have all this chat on email? You know, it's maybe not a good idea for us to be having these conversations on email." So y- you have a very clear awareness that there's a problem. And if you back up for a second, part of the reason OxyContin did what it did, part of the reason I, I would argue it, it changed the way in which these drugs are prescribed as a, as a category of drugs, is that they had one of the biggest marketing forces ever and they sent out hundreds of sa- something like 700 sales reps to fan out across the country, um, meeting with thousands and thousands of physicians and that was how they kind of got the message of OxyContin out there. But, but those are the canaries in the coal mine, right? Like, th- those are, the, the sales rep who goes into a local commun- There's a story I tell in the, in the book about, um, a guy named Steve May, who was a Purdue sales rep in Virginia, uh, and West Virginia, and he had a, um, it's '99, so this is, like, before, according to Goldenheim, like, they didn't know anything at this point. It's '99. Um, Steve May had this one doctor. The, the really big prescribers, they would call them whales, um, you know, to use the vernacular of a Vegas casino for a, a big gambler. Um, because if you had a big prescriber, that was great for your, for your bonus if you were a, uh, a sales rep. So Steve May had this whale, and, uh, he went to call on her, which he would do from time to time, and y- she was upset when he showed up, and he asked her what the problem was, and she said she had a young relative, uh, a young girl who'd just died of an OxyContin overdose. So there you literally have an OxyContin sales rep going out on a meeting with a doctor who's a big prescriber and finding out that her relative has died from an OxyContin overdose, and all those reps are writing these encounters up in notes and sending them back to headquarters. So I think what I was able to substantiate in the book at some length is that, um, it's clear really early on there's a problem, I think, y- you know, from as, or as early as '97, so that's just a year after the drug is released. And, um, word is coming back into the company, and those discussions are not just happening at low levels, they're happening at high levels. I think what happens in 2000 is it just becomes impossible for them to deny it anymore, right? It's like at that point, the sort of head in the sand won't work as a strategy, so then you need to pivot. You need to say, "Okay, there is a problem. Here's our spin on it."

   11. PAPeter Attia53:26

       And that spin of course became, these are really bad people. Like, you know, we've created a miracle breakthrough product that helps millions of people, but there are these derelicts who abuse this product and are jeopardizing it for everybody else. We really need to ramp up the enforcement of those people, or we need to somehow just decide that they're ba- I mean, what, what was proposed as the, um, the remediation for the problem?

   12. PKPatrick Radden Keefe53:59

       It was a bunch of things, all of which were very much along the lines of what you're talking about. So the, the suggestion was, you know, there's nothing intrinsically dangerous about the drug. Um, I should say the level of denial here is pretty impressive, but I mean, the Sacklers even today argue that, um, that instances of, of iatrogenic addiction to OxyContin, where you're, it's prescribed to you by a doctor for a leg- legitimate condition and you take it as, as instructed by the physician, are vanishingly rare. They, that's, that's like a, a block that they have where they, they, they can't really

8. 54:35 – 1:06:33

   The many paths to addiction and abuse of OxyContin and the ensuing downfall of Purdue Pharma

   1. PKPatrick Radden Keefe54:35

      acknowledge even today.

   2. PAPeter Attia54:36

      Now, do we know what that true number is? So if we, if we, if we say there are th- and, and I'm being a bit perhaps overly simplif- overly simplistic, but, but, and, and so feel free to make this more-

   3. PKPatrick Radden Keefe54:49

      Mm-hmm

   4. PAPeter Attia54:49

      ... realistic, but if we say there are three buckets in which a patient, a patient came across OxyContin, bucket one would be, uh, and this excludes the cancer patient. So I want to take the end of life cancer patient out of the equation for a moment. So if you, you, you talk about patients who are not terminally ill, who re- who are, um, on, who have become exposed to and/or addicted to OxyContin. Um, entry path number one is the individual who Is recovering from surgery. They are, by their, by their actual doctor, who is a legitimate doctor, given a prescription for a reasonable quantity of OxyContin that should get them through the perioperative period. Okay. Path number two is the person who-- And by the way, you can get to path number two from path number one, so these are not independent paths. But path number two is the sham doctor, right? The, you know, the doc in the box who's prescribing this stuff from one state when you're in another state, doing it online, uh, or running basically the, you know, the revolving door clinic where you just come in, you ask for what you want, you get a prescription, you go out the door, provided you fill it at a pharmacy a couple hundred miles away. So, you know, they're a doctor only in legal terms, but they're certainly not a physician in any reasonable sense of the word. And then path number three is the illicit acquisition of OxyContin through a, a stolen channel. So in the, much in the same way you would buy any illegal drug, you're simply buying OxyContin. Do we have a sense of the relative distribution of paths one, two, and three?

   5. PKPatrick Radden Keefe56:25

      No, and I mean, I think it's, it's, it's very hard and, in fact, impossible to parse it out, and I also think it's, it's something that's, that's fluctuated a lot over time. But you do get these, these little data points that I think are illuminating. And these are, these are honestly, like, two of the more shocking things I, I discovered in, in, in my research, but the, it, but it's hard, 'cause it's, it's a little complex, and so sometimes I think the, um, from the, from the cheap seats, it's, it's, like, hard to, hard to appreciate the gravity of this. So Purdue sells OxyContin, they release it in '96. Right away, people realize that that, that contin seal, you can override that just by crushing the pills. So you can chew them, you can grind the pill, um, you can dissolve it in water after you've grind it and ch- and shoot it if you want intravenously. Um, there's actually a warning on the bottles telling you not to crush the pills, because if you do, you could get a potentially toxic dose of oxycodone. So, so in a weird way, that functions as a kind of inadvertent how-to. I think that's significant for, um, at, at least, you know, maybe for all three of the buckets you're talking about, because you get people who, um, are just kind of opportunistic drug users looking to get high. Uh, y- y- you know, I, I certainly have interviewed a lot of people who say that heroin was scary. You bought it on the street, you shoot it with a needle, that, you know, they were looking to get high. It was like a party drug in high school, OxyContin was. But that they, there was something reassuring about the fact that it had been approved by the FDA, that it is, you know that even if you bought it from a dealer, uh, at some point, this entered the stream of commerce, you know, and there was a doctor writing a, a prescription. Um, you also have people who, who, you know, uh, are prescribed the drug by a doctor and it doesn't work for as long as they think it will, or they find theirselves just, themselves just kind of in its grip. They want more, and some of those people actually convert to the immediate release thing. What they find is they, they don't want to wait, and so they'll end up chewing the, the pills, um, because it relieves their pain faster, you know, is, is what they'll say. Um, so you get different ways of getting there, but, um, the pill can be crushed. That's '96. In 2010, Purdue rolls out this reformulated version of OxyContin that they've worked on for years. It's basically you can't crush it. It's sort of, it's like a gummy bear. You know, if you, if you try and break it up, it just kind of goes chewy and gummy on you. Um, there's an interesting backstory there, questions about why it took so long to roll that out. There's an interesting aspect of the timing, which is that the original patent on OxyContin were about to run out, so it kind of just in the nick of time they have this, um, line extension basically in the form of the reformulated drug. But this is, this is-

   6. PAPeter Attia59:18

      Well, well it goes one better than that, doesn't it, Patrick? Because at the time, they even basically declare that their old formulation is probably unsafe, which is really a great dig at the competition, which is, as we're about to roll this thing off its patent life, we wanna make sure that nobody else uses it either as we reignite a new patent on a new drug, which is infinitely safer in the presence of our old dangerous drug. I mean, again, that would be the skeptical view of things.

   7. PKPatrick Radden Keefe59:45

      Oh, I mean it, uh, and I think in this case, the skeptical view is, is, uh, is right on. And in fact, there are emails going back years and years and years talking about how if they came up with a, with a, a kind of abuse-proof, tamper-proof formulation, that would function as a line extension, that that was the reason they were doing it, primarily was to extend the patent life. Um, but yeah, the, the kind of, um, uh, the surpassing cynicism of the idea that having for, at that point, 14 years said, "Oh, it's perfectly safe, it's perfectly safe, it's perfectly safe," the original formulation. They developed their new formulation and then they turn around and say, "Well, we wouldn't wanna see any generic versions of the original formulation because in fact, it's not so safe after all," um, is amazing. And it worked, and the FDA obliged. But, so here's the s- statistic that really blows my mind. 2010, the reformulated version is rolled out, and the old pills, uh, are, you know, they kinda disappear from the shelves, and the new ones take their place. And what I discovered was a study, an internal study that found that in 2010 when this happened, for the 80 milligram pills, which was the biggest and most profitable pills on the market, also the most popular on the black market, sales nationwide fell 25%. So I can't tell you, you know, proportionately who's in what bucket. What I can tell you is that up to 2010, I think it's safe to intuit 25% of the sales of 80 milligram OxyContin were going to people who were abusing those pills In, you know, in one way or another. Um, which is astonishing to me because, I mean, that's, that's a hu- that's like an, a non-trivial part of the company's profits. So on the one hand, it's, you know, they don't want their patients, their, their, their customers to die. Um, on the other hand, there is a sense in which even as they were decrying the black market, like the black market was helping to pay the bills at the company.

   8. PAPeter Attia1:01:47

      Yeah, and the thing that, the thing that I really wish we could have an insight into is even if you take the most charitable view of things, which is that every person's first interaction with OxyContin was through path one, that is to say you were legitimately prescribed this for non-cancer pain by a legitimate, caring, understanding physician. But then w- you know, a subset of the people left bucket one for bucket two or bucket three as their appetite for the drug grew in the absence of an indication, right? That's-

   9. PKPatrick Radden Keefe1:02:21

      Mm-hmm, mm-hmm

   10. PAPeter Attia1:02:22

       ... versus how many people de novo show up in bucket two and bucket three drug-seeking. Um, you know, the fact that we don't know that is ... It makes this very difficult and creates this moral ambiguity around it, which, um, you know, frankly is a bit of a distraction from the real, you know, the culpability here.

   11. PKPatrick Radden Keefe1:02:42

       Oh, that's interesting. I mean, I, I think it's, it's a very, um ... I think the fact that we don't know it and that it's impossible to know, combined with the fact that when you look at, you know, this is a favorite of Purdue and the Sacklers, but, like, when you look at the, um, toxicity reports on people who die, people who overdose, it's often not just OxyContin in the bloodstream, right? It's often mixed with other things.

   12. PAPeter Attia1:03:05

       Right.

   13. PKPatrick Radden Keefe1:03:05

       Um, there's this whole kind of, um, exercise of parsing, like moral and legal parsing that they do, um, which, you know, I, I have to say for me just as a, y- uh, as someone who's trying to live a righteous life, it, it, it's always amazing to me 'cause I always just think, I can't imagine, how do you get there? Like, how do you, how do you get there? H- I, at a certain point, so many people have died from your product. Um, it's this kind of incredible symphony of rationalization that happens. But, but on your, on your, on your point about, you know, everybody, the idea that, you know, ideally you'd have a situation in which everybody sort of enters through bucket one, um, let me give you the other statistic, which is that we'll get to this, but Purdue Pharma is now in bankruptcy, and in the context of the bankruptcy, there are many, many, many creditors who have a, a claim that they'd like to exert against what's left of the company, and one of them is UnitedHealth. And UnitedHealth had this fascinating filing, um, where they were, they were, you know, talking about the idea that they should have a piece of the pie, such as it is, and, uh, we'll leave aside for a second whether a big insurer should, uh, um, you know, should, uh, be there in line along with all these people whose lives have been ruined by the drug. What was interesting is that they said they ran a study, and I, I don't remember how many years it was, but it was, it was over the course of something like seven or eight years. They looked at people who had, uh, UnitedHealth plans, um, and who, uh, were prescribed OxyContin or another Purdue opioid, um, and subsequently diagnosed with an opioid use disorder. So I, I think that would actually be a kind of a smaller subset because you, you literally have a diagnosis-

   14. PAPeter Attia1:05:09

       Right

   15. PKPatrick Radden Keefe1:05:09

       ... uh, of an OUD. And they said that, so for, for that subset, prescription from a doctor, subsequent diagnosis, just UnitedHealth over seven or eight years, they said the number was in the hundreds of thousands.

   16. PAPeter Attia1:05:24

       And did they say, what, what, I mean, I'm sure it would be in the study, but what percentage of that, w- what percentage of people was that who were initially given a prescription? Was that 10%, 20%, 50%?

   17. PKPatrick Radden Keefe1:05:35

       Oh, that I don't know. That's interesting. I don't know. Um, it probably was in the, in the study, but it's not, it hasn't been, you know, it was not revealed in, in the filing to the bankruptcy court.

   18. PAPeter Attia1:05:45

       Hmm. That would be interesting 'cause that would, that would actually shed great light on this issue.

   19. PKPatrick Radden Keefe1:05:50

       It would. I mean, I, I think to me the, the thing that's interesting is that it remains a talking point, uh, certainly for the Sacklers and their legal counsel, that it's, it's virtually impossible if you, you know, if you're a pain patient and you're prescribed the drug by a doctor and you, and you take it as directed to become addicted, um, to, to, to, to put that side by side with this hundreds of thousands number, um, is extraordinary. Even if you build in a discount where you say, "Okay, well, some of those people probably did, you know, some of those were, were fraudulent docs or fraudulent patients or what have you," um, y- you still end up with a, a really huge number of people who ha- who have become hooked on the drug, uh, in the, in an iatrog- iatrogenic

9. 1:06:33 – 1:19:44

   Peter’s personal experience with OxyContin

   1. PKPatrick Radden Keefe1:06:33

      context.

   2. PAPeter Attia1:06:35

      Yeah. So, so, you know, I have a real personal history with this, which I, I'm sure you'll appreciate. Um, I wasn't sure I was gonna tell you this story, but I, I think it's, it's appropriate here. So I, in some ways I feel very lucky to be sitting here having a discussion right now as opposed to being dead. Um, a little over 20 years ago when I was in my last year of medical school, I had a really bad back injury. Um, kind of, you know, sort of hurt it kind of acutely, and for two and a half weeks just ignored it, the pain, but the pain grew more and more debilitating. I remember I was doing a rotation, you know, one of my rotations, and I, I couldn't even sleep. I had to get, you know, the residents to inject Toradol into my thighs just to allow me to have enough, you know, of an inkling to be able to sleep for a while. So finally at some point I just agreed to go get an MRI and look, and sure enough, um, there was a really bad herniation In my lower back, and a, about a five-centimeter fragment of disc had broken off on the left side, and it floated down the canal, and it was sitting on the S1 nerve root, which is what was causing this almost comical amount of pain. I say comical now because it's hard to even describe. There's nothing funny about it. So I underwent surgery the next day. [lip smack] Um, but surgery didn't go well for a number of reasons. Um, th- but the surgeon operated on the wrong side. So I woke up from the surgery in terrible pain, but also with a new complication on the other side. [lip smack] Um, this resulted in a number of follow-up procedures initially aimed at correcting the first problem. But before I knew it, you know, even once this, the structural problem had been fixed, the pain was so bad that I finally relented and agreed to take pain medicine.

   3. PKPatrick Radden Keefe1:08:22

      Hmm.

   4. PAPeter Attia1:08:22

      I had been horribly petrified of taking anything beyond NSAIDs. [lip smack] So what was the first drug? This is the year 2000, so what's the first prescription I get? It's for 20 milligrams of OxyContin to be taken, I believe, twice a day. I, I think you take 20 in the morning and 20 in the afternoon or evening or something like that. But you can, can, you can probably imagine where this story is going, Patrick. How much OxyContin do you think I was taking within four months?

   5. PKPatrick Radden Keefe1:08:48

      Tell me.

   6. PAPeter Attia1:08:49

      Almost 400 milligrams a day.

   7. PKPatrick Radden Keefe1:08:52

      Unreal.

   8. PAPeter Attia1:08:54

      So again, maybe for the listener who doesn't know what that means in context, that would be enough to kill an entire family of drug-naive people, right? That, you know, 400 milligrams would kill Mom, Dad, Susie, Bobby, Sally. They'd just stop breathing. So it didn't take long for me to go from 40 milligrams a day to 400 milligrams a day, and there are a couple things about this that are interesting. The first is that was all prescribed by a legitimate doctor-

   9. PKPatrick Radden Keefe1:09:23

      Mm-hmm

   10. PAPeter Attia1:09:23

       ... who was not at all an expert in pain management. This was a, a surgeon who had already demonstrated gross incompetence [chuckles] in not operating on the right side. Um, no one was monitoring how much of this drug I needed. The dose just kept going up and up and up.

   11. PKPatrick Radden Keefe1:09:40

       Mm-hmm.

   12. PAPeter Attia1:09:40

       [lip smack] Um, I was very fortunate at the time to be dating an anesthesiology resident. So she was about three or four years older than me, actually probably in her last year of anesthesia. Um, and she herself was actually interested in pain management, so she would go on to do a fellowship in pain management. And, you know, she was a bit troubled by how much of this drug that I was on, and that sort of got me thinking, like, "How the hell did I get here?" Because it happened so quick, right? It was, you know, one minute you're like, "I never ever, ever wanna take one of these drugs," and then the next minute you're basically in a day... You're in a constant haze. You're, you know, there was no moment that I wasn't high. The turning point for me came when I realized that I couldn't differentiate between the pain relief and the high. In other words, [lip smack] I realized I was probably taking the drug to avoid the psychological pain, which at the time I was pretty convinced I'd never walk again. Uh, this was a one-year recovery process, but the first three months I couldn't walk. So that basically shattered all of my dreams. I was no longer gonna be able to be a surgeon, I believed, uh, let alone be an active, healthy person that I'd been all my life. And so I was actually taking this drug just as much to blunt that grief as I was taking it to blunt the pain. And finally in, in, in the fall of that year, I just decided this is not-- I don't wanna do this anymore. I, this is... You know, I never imagined I would overdose. That's the other thing, by the way. It never even crossed my mind that I could get to a point where I would stop breathing. Um, but I just thought, "No, I can't do this anymore." So I said to my girlfriend, I said, "I'm gonna stop this cold turkey." And she said, "You absolutely can't do that. The withdrawal from this will kill you just as much as this drug will kill you. You need to be on nortriptyline, morphine." I mean, she rattled off all the drugs I would need-

   13. PKPatrick Radden Keefe1:11:46

       Mm-hmm

   14. PAPeter Attia1:11:46

       ... to take to taper off. But I was a stubborn kid, and I just stopped cold turkey, and the next three weeks of my life would be about the most miserable three weeks of my existence. I certainly hope I don't have another three weeks somewhere [chuckles] down my life that will be that bad. Um, but here's the thing that is interesting. I'm not telling this story to, for a moment suggest any superiority, like, "Look at me, I was able to come off this drug." I, I... What my point is that what I've learned about addiction since then would suggest that I'm simply biologically lucky. In other words, I truly believe that, that the neurotransmitters in my brain are not wired the way that someone who, in that exact situation, would've become a lifelong addict. So that's, that's why I say I'm very lucky. I'm not lucky because I have willpower. I'm lucky because that chemical didn't put a hook in me the way it would in others. So in other words, I had become physiologically dependent on it, and that's why I went through withdrawal just as anybody would. But I'm really lucky that I was man- I managed to escape this drug. And it's, it's interesting. I was still deathly afraid of the drug after the fact.

   15. PKPatrick Radden Keefe1:13:06

       Mm-hmm.

   16. PAPeter Attia1:13:06

       And only seven years later, when I had a really, really bad dental issue, would I ever touch another Percocet in my life, which of course is a fraction of the drug.

   17. PKPatrick Radden Keefe1:13:17

       Right.

   18. PAPeter Attia1:13:18

       And I remember being really worried, like, "What's going to happen? Is this going to escalate into massive use?" And fortunately, it didn't. You know, I needed Percocet for, like, a week until I had a tooth extracted And then I, I just stopped it, and that was fine. But you know, it paradoxically gave me more empathy than self-righteousness over the people who became addicted. I don't know why. You- it- that's not obvious why that would be the case, but I, I think I just sort of believed that there are some of us who don't get addicted to these things, even when exposed, but there are enough people who do, and I don't know what that number is, right? And to your point-

   19. PKPatrick Radden Keefe1:13:59

       Mm

   20. PAPeter Attia1:13:59

       ... I don't know that we can ever know that number. But I agree with you that that doesn't remove the moral obligation of the people that were involved in exposing, people like me, and people much less fortunate than me.

   21. PKPatrick Radden Keefe1:14:13

       Yeah. I mean, I, I, I would imagine that part of the reason that you, that it gave you a kind of, um, [lips smack] you know, a sense of compassion for those who, whose experience has, um, you know, turned out much worse is that the, it does sound as though you encountered the ... I mean, I've talked to so many people who, who, who've, whose lives have been upended by this drug and other opioids, and the, um [lips smack] you know, it's often like there's a kind of undertow, right? There's just this sense that, that, that you, you're suddenly in the grip of something. And, and, you know, y- you manage to get out of the grip, but it sounds like even you were, in terms of the physiological dependence and the idea that you were titrating up so fast-

   22. PAPeter Attia1:14:57

       Th- that, that upward speed was unbelievable, Patrick. I mean, unbelievable-

   23. PKPatrick Radden Keefe1:15:03

       Yeah

   24. PAPeter Attia1:15:03

       ... how quickly a tolerance developed. And by the way, it's total bullshit to say you don't get high from a time-release drug.

   25. PKPatrick Radden Keefe1:15:09

       Yeah.

   26. PAPeter Attia1:15:09

       I mean, maybe I, I don't know what it's like to take heroin, so I'm sure compared to heroin it's, it's-

   27. PKPatrick Radden Keefe1:15:13

       Right

   28. PAPeter Attia1:15:13

       ... it's blunt. But there is an absolute blast-off high that came from those mega doses of that drug.

   29. PKPatrick Radden Keefe1:15:22

       Yeah. What's so intriguing to me, though, about, about your story is, is actually the doctor, right? The idea that you have a surgeon who writes you the prescription. And um, you know, part of what's so fascinating is that the, the drug companies, Purdue and the other companies, argued from the beginning that the doctors don't know enough about pain management. They haven't gotten the training. And there was some truth to that, but the weirdness of it is they then rush into the vacuum and they say, "We'll provide that training. We'll do that education." And the, the catchphrase for OxyContin early on was that it's, it's the drug to start with and to stay with. And so the, you know, the first part of that, right, is it's like this isn't some nuclear solution you keep on the top shelf where you would try other courses of therapy and only when those fail do you resort to it. It's the first thing you should administer. And then it's the one to stay with, meaning you can just keep taking it, you know, for chronic pain conditions year in, year out, even if you have to keep titrating up. And it was a, a, a core belief at the company, Richard Sackler felt very strongly about this, that there was no, you know, what was, what he described as no ceiling effect with OxyContin. That in fact, um, you could just keep taking greater and greater doses, which you would need to as your system accom- accompanies itself to it. And then you have the, the pharmaceutical reps who are meeting with doctors like your surgeon and are heavily incentivized to get those docs to titrate up. That's always the message because, uh, you know, the, the, the, the profits and in fact even the bonuses for the pharma reps were all based on, on the volume of, uh, the drug that's, that's sold and, and prescribed. So i- it's just funny 'cause I, you know, hearing your anecdote fr- from your side, what I see on the other side is this sort of perfect storm of scenarios where, um, you know, w- when you're thinking about [chuckles] like do I go cold turkey, do I taper off, should I be taking morphine, you're having those conversations with your girlfriend because the guy who prescribed you the drug probably doesn't know how to explain to people how to get them off. I mean, you have this kind of crazy situation in which you have a generation of doctors who learn how to, how to like on-ramp their patients with these drugs and never learn how to off-ramp them, and actually kinda don't necessarily have any interest or inclination. And if you talk to people who've had these experiences, they'll say, "I went back to the surgeon who, who wrote me the original script," and I said, "Hey, listen, you know, I'm a, I'm having problems here," and they say, "Whoa, whoa, whoa, I'm not an addiction specialist."

   30. PAPeter Attia1:18:05

       Right.
10. 1:19:44 – 1:30:17

    Pain—the “fifth vital sign,” how doctors are trained in pain management, and the influence of money

    1. PKPatrick Radden Keefe1:19:44

       Yeah.

    2. PAPeter Attia1:19:45

       So, you know, that part of the story also speaks to the incredible fortune that I had that many people don't have, and maybe had I not had it, there still would be a different ending, right? It still might have been that, well, after three months of going cold turkey, I had to go back because there was no alternative. And i- it's funny. I'll tell, I'll tell you about it. When I was in my residency, I was still amazed at how ignorant we were as surgical residents of pain management. I mean, completely ignorant. There was absolutely no teaching of this subject matter. Something that I learned that was very simple was studies had demonstrated that before you do an incision on a patient, if you inject Marcaine, which is a long-acting, uh, sodium channel blocker, like a, you know, like the type of in... You know, like a Novocaine-type thing that the dentist would-

    3. PKPatrick Radden Keefe1:20:36

       Mm-hmm

    4. PAPeter Attia1:20:36

       ... put in your teeth. So you have lidocaine, which is short-acting; Marcaine, which is long-acting. If you inject the incision site with Marcaine before you cut, you wait a moment, you then make the incision, and then immediately following surgery, you put the patient on a pretty aggressive dose of NSAIDs, many patients can actually avoid narcotics postoperatively for the incisional pain, which is the dominant source of pain.

    5. PKPatrick Radden Keefe1:21:05

       Yeah.

    6. PAPeter Attia1:21:05

       And I remember thinking, "Why aren't we doing this with every patient?" And I, I got into an argument with one of the attendings because I was about to do an operation and, you know, I was, I went to do this, and he said, "Come on, come on, come on. That's gonna take five minutes. You've gotta, you know, put that in, and then we have to sit here and wait five minutes with our dicks in our hands while it sets in before you cut. No, no, no, no, we don't have the time for that." And I remember thinking, "Really? We don't have five minutes?" You know, it was shocking.

    7. PKPatrick Radden Keefe1:21:34

       Yeah. Yeah. But, uh, but listen, I mean, I, I think in a weird way, [laughs] a- and I say, I'm not a doctor, right? I say this, I say this coming from the outside. B- but, but having done a little bit of a, a, a kind of anthropological, uh, bushwhack through this world over the last few years, uh, you go back to what we were talking about earlier, where you have the Sackler brothers in the 1940s and '50s saying, um, "Wouldn't it be beautiful if someday there was just a pill you could take for everything?" [lips smack] And, and particularly Arthur Sackler kind of trying to sort of intermingle medicine and commerce in, in ways that I think ended up being more profound than, than, than anybody could have probably recognized at the time. From the outside, I, I think that one of the ingredients that gives you the opioid crisis is actually, uh, that idea of, like, we wanna waste five minutes. You know, we, we need to get, we need to get our patients in and out. Um, uh, uh, time is money, and there was a, um... You know, I've interviewed, uh, I've interviewed doctors who talk about the, how they felt duped, how when the, when, when the Purdue sales reps started flogging OxyContin, you know, if you're a doctor, you encounter patients who are in pain. You wanna relieve that pain. You know, it's often, it's, it's kind of in some ways inherent to why you chose to do this in your life, right, is you wanna, you wanna bring relief to people who are suffering. Um, and suddenly there's this medical innovation which you're told, uh, i- is like a, a panacea. It can relieve that pain, uh, and has virtually no side effects, and people can take it forever, and there's no dosage ceiling. Um, and so, you know, I've, I've talked to people who've said, just earnestly, "That was a siren song I was all too ready to listen to because, um, it, it, it filled a, a need in my, you know, in my kind of therapeutic arsenal." Um, and of course it ended up being more complicated. B- but I also think that when you think about the way in which American medicine is structured, um, the idea that you have a patient who's in pain and you say, "I'm gonna write you a prescription for, uh, 20 milligrams of OxyContin. Be on your way. Um, I never have to see you again. I, I'm not really gonna give any thought to how this is working out for you two weeks from now or two months from now or two years from now," um, [lips smack] I think that the, uh, th- that notion that, you know, that five minutes is money, right? Five minutes is, is, is... You know, that five minutes is five minutes you're not spending with the next patient. Um, it- it's a longer line in the waiting room. I think those kinds of structural considerations we- were part of what allowed, um, Purdue and other opioid makers to kinda snow the medical establishment as effectively as they did, where if you look at, at, at the, the prescribing levels for these drugs, with the introduction of OxyContin, they just suddenly start climbing in this really dramatic way. And you would think that there would have been more skepticism, that it would have been slower growth, but I do think there was a sense in which it sort of, it filled a number of needs, right? And that was what allowed it to take off the way it did.

    8. PAPeter Attia1:25:01

       [lips smack] Well, it also seemed to become very politically correct in the sense that they somehow managed to infiltrate the AMA. I mean, one of the other memories I have from, you know, the early days of residency was how all of a sudden a new vital sign emerged. So vital signs are, by definition, objective. So they are things that can be measured for which there is no ambiguity: temperature, pulse, respiratory rate, blood pressure. But then a fifth vital sign got introduced, which was pain, a subjective measurement on a scale of one to 10. And there were laminated posters on every corner of the hospital. "Don't forget the fifth vital sign. Don't forget the fifth vital sign. What is the fifth vital sign? What is your patient's pain?" I mean, it was, you know... And this really came from the medical community. This, this was some- this was a form of self-policing. So how involved was Purdue in driving that agenda?

    9. PKPatrick Radden Keefe1:26:05

       I mean, I, I wanna be careful about how I put this. Very would be the short answer. Um, but I think you have this tricky thing. It's a little bit like when I, when I [chuckles] was talking about Curtis Wright and, and the FDA, and how there's a kind of soft corruption that happens, which is, which is, you know, it's not as glaring as the kind of caricature-ish corruption, uh, that, that you would think of. I think there's a similar thing here where y- you have the American Medical Association, you have, um, all kinds of, uh, groups, uh, you know, groups of doctors, groups representing patients, patients' rights, um, you know, kind of pain advocacy groups. And, um, and then you have industry, uh, underwriting a lot of this stuff. And there, you know, there's just a, a quite a good piece in, um, Mother Jones just recently about the AMA and, and, um, you know, the, uh, Richard Sackler was on one of these boards, and you have, um, a lot of money going to sponsor education.

    10. PAPeter Attia1:27:10

        Yeah. Well, that, that, that's, I just read that Mother Jones piece, and I couldn't believe that the AMA, both as an organization and its foundation separately, are receiving money from the Sacklers.

    11. PKPatrick Radden Keefe1:27:24

        Yeah. Yeah. And, and then, and then often what happens, right, is that you get these things where it's, there's like an educational pamphlet that they end up distributing. There's a kind of laundering that happens, a sort of institutional laundering, right, where, um, where industry comes up with these educational brochures, or they sponsor research or what have you. I mean, the example that I love from, from [chuckles] that story, the, uh, the Mother Jones story, was that there was one kind of handy guide to pain and the fifth vital sign, and the idea of, uh, how do you talk to a child about the pain they're feeling? And, and there was, there was a kind of a, an admonition to the doctors that you, remember, you know, you gotta tell the child that no pain is not an acceptable answer. You know, it's, there's a continuum, but the [chuckles] but the end of the continuum where there's no pain, you know, that's, that's, that's not, not, uh, not an option. Um, the, uh... Yeah, I think it's tricky because I, I, I just think that a lot of the time it's not necessarily that, um... I think it's more a coincidence of interests in which you have people who earnestly believe these things and then are underwritten by industry, and that kind of turbocharges the arguments they're making, um, more than it is a situation of docs being paid off to tell what they know to be lies, right? And I think there was a kind of... Like, when you, when you talk about the idea of the fifth vital sign, even just that phrase, on the one hand, I think that there was some truth to the critique that, that there hadn't been enough education in pain management and enough consideration given to how you relieve patients' pain. Um, I think as a critique, that had some truth to it. On the other hand, when you say the fifth vital sign, like, to me, that sounds more than anything like a great marketing slogan. I don't know who dreamed that up, um, but it, it sounds like something that an advertiser would come up with, right? It's catchy. It's kinda pithy. Um, and of course, it's totally subjective. Um, there was a study, I couldn't give you the citation, but I remember reading this, reading about this great study, um, where it was like the scale of one to 10 thing, right? And they found that it's not just that it varies, that you, you may have, you know, what, what might be a, a seven for you could be a, a nine for me, um, but that it actually [chuckles] varies regionally, where they, you know, they found that, like, people in Northern Europe, um, y- you'd, you'd, you'd exert some sort of standard amount of pain, and they would say, uh, you know, "Oh, that's a four." And then people in Southern Europe, you'd exert the same amount of pain, and they would say, "It's a 10! It's a 10!"

    12. PAPeter Attia1:29:56

        [laughs]

    13. PKPatrick Radden Keefe1:29:56

        Um, but you know that you actually get these kind of cultural regional differences in terms of, uh, people's pain thresholds. So the, um... It, it's hard because I do think it's a, it's a, it's a legitimate thing that, that people should be looking at and inquiring about, but at the same time, it's totally subjective, and, and I think that again and again, you see just the money pollute everything.

11. 1:30:17 – 1:39:48

    Other players that helped facilitate the eventual opioid crisis

    1. PAPeter Attia1:30:18

       You know, you mentioned earlier that Curtis Wright effectively, um, [tsks] um, whe- whether, you know, in a, in a direct quid pro quo or more of just a, a confluence of, of interests, not only basically approves this drug single-handedly for the FDA, but then ultimately winds up working for this entity. But, you know, the other story in this one that really blew my mind was that of Lyndon Barber at the DEA, a guy who on, on the one hand is, seems by all accounts to be one of the most, uh, credible voices within the DEA to standing up to the, you know, unmanaged distribution of these drugs, and then kinda does an about-face and becomes one of the most powerful lobbying entities for the very companies. I believe Cardinal was one of his largest clients, Cardinal McKesson being two of the largest distributors. Um, kind of hard to believe. But at the same time, I guess you, you know, going through the, what you said earlier, it's like, look, how long can you work for nothing as a government employee, right? And at some point, he has a choice, which is he's gonna go make a living harnessing his existing skills. But it just doesn't feel right, you know? I, I don't know, I don't know how else to put it. It just doesn't, it just doesn't sit well with me.

    2. PKPatrick Radden Keefe1:31:47

       Yeah. You know, I, I, um... It's funny. I, uh, it, it's, it's very, uh, [laughs] you know, uh, uh, I don't wanna sound like a scold or preachy, um, or somebody who's holier than thou, or like a Boy Scout, 'cause, 'cause I'm not, um, by any stretch. But the... But it has been one of the more dispiriting things working on this project, where, um, you know, a lot of the time in the past I've written about crime a fair amount. And, and, and you, it's just kind of baked in that you're writing about a bad person doing a bad thing, and they kinda know they're bad, usually. Um, and there's a sort of moral clarity there. Uh, what was so fascinating to me about this story is that, you know, I think the Sacklers are, are, are kind of, are bad actors. I think they, they did really bad things. Um, and they're the focus of the story. But then around them are all of these facilitators, and it's, it's former prosecutors who go and work as private defense attorneys for the family or for the company. It's former DEA officials who go and work as lobbyists for the industry. It's former FDA officials who go and work at the company. Um, it's, you know, folks at McKinsey. It's this whole kind of amazing entrenched machine of people who I think in many instances don't think of themselves as the bad guys. Um, and in some cases, society doesn't think of them as the bad guys, right? You know, um, one of the characters in my, in my book is Mary Jo White, this, you know, former US attorney for the Southern District of New York. Uh, former, she was Obama's head of the SEC. She's a, a hero to lawyers, many wor- you know, all over the place. A, a, a woman who kind of broke the glass ceiling. Um, and she's represented Purdue and the Sacklers for years, and is totally a handmaiden to them. So I, it's a thing that I've kind of wrestled with personally. I'm a lawyer by training, and I know that, um, there is a sort of, it, it's, it's very fundamental to the ethos of the profession that, you know, you're, the lawyer isn't the client, and that we shouldn't necessarily, um, kind of transpose the, the, the moral stink of the client onto the lawyer. But it's hard for me when, you know, you, you tell the Linda Barber story. There's a hundred people like that in the book, um, who, who play that kind of role. And again and again and again, you get these people who are supposed to be the cops, basically. They're supposed to be law and order, and they get co-opted by the money, and it's, um, it's really discouraging.

    3. PAPeter Attia1:34:36

       And, and sometimes I don't get it 'cause the money isn't even that much. I mean, when you look at Chris Dodd and Marsha Blackburn and Tom Marino and Orrin Hatch, I mean, it's just hard for me to look at these people and think of them as reasonable or respectable, truthfully, you know, when I look at their involvement in the bills that they sponsored and the positions that they took in all of this. And when you look at the dollars that they received from the-

    4. PKPatrick Radden Keefe1:35:00

       They're bought so cheaply.

    5. PAPeter Attia1:35:02

       Yeah, that's exactly the point, Patrick. You know, I expected that it would have taken tens of millions to have bought those people. They were bought for hundreds of thousands of dollars. US senators for sale for hundreds of thousands of dollars? I, I don't understand it.

    6. PKPatrick Radden Keefe1:35:21

       I think, yeah. I mean, I think it's so, so I think the thing is it's, some of it is the, is the money, um, donations and what have you, but I think there's this other thing that is more about the revolving door and the kind of this insidious thing where the, it's the lobbyists, and the lobbyists are often people they know, right? And it's a kind of, um, uh, you know, you see this with the way in which Purdue and the Sacklers would use lawyers. Like Mary Jo White is a good example, or they hired Rudy Giuliani for, for years was kind of their hatchet man. And it's like if you were a federal prosecutor and you're investigating me, um, the real move is to not to sort of fight it out with you on the merits in court the way most people would. It's for me to go to your boss, but not for me personally to go to your boss. For me to find somebody who your boss knows and respects, and, and that's the person I buy off, and I send them to go and kind of make the overture. And so I, I think when you look at these people, it's not just that they're... Again, it's the sort of soft corruption thing, where some of it is the, it, it, it's not like campaign contributions. It's that you're, you know, [laughs] it's like the, it's the, you know, it's that scene in The Godfather where the, um, where the guy's supposed to testify in, in court, and they send, they get the old guy from Sicily to come and just sit in the courtroom, and it happens to be his uncle or whatever, and he sees the guy in the courtroom and he, he suddenly sort of loses all his moral conviction and decides he's not gonna testify. It's sort of that. Um, it's, it's like being really smart and strategic about who's the right messenger. Um, who would we send to make the case to Chris Dodd, um, you know, about why he shouldn't come after us, uh, or, or why he should, um, you know, help us in this or that? And man, they're really good. Really, really good at that.

    7. PAPeter Attia1:37:18

       And it's interesting at how, if, if I wanna use the word, you might not use the word, but if I wanna use the word corruption, how bipartisan the corruption was.

    8. PKPatrick Radden Keefe1:37:26

       Totally.

    9. PAPeter Attia1:37:27

       Um, what was the bill? H.R.4709. The, what would the... Th- this is the sleeper bill, right? It's like this three-page nothing burger that basically opened the pipelines to move these drugs and put the DEA's hands behind its back. I mean, again, it's a little detail, but my God, it's amazing how unopposed that bill went.

    10. PKPatrick Radden Keefe1:37:54

        Yeah. But I mean, this is e- absolutely. But, but, but some of that I think is the fact that nobody's really reading the bill. The bill was carefully designed to look like it was sort of doing the opposite [laughs] of what it was doing, right? It's like we're gonna fight the opioid crisis. Um, you know, Obama signed it, and who knows how closely he looked at it. Um, I, I think that there's a, there's enough business that goes on in Washington, and I think particularly when it comes to lawmaking, you know, you have these members of the House and senators who are... They spend all their time raising money. Um, they, uh... I- if you can make what you're doing look like business as usual, y- you can pull it off. Um, it's, uh, it's super dispiriting. But a- but again, I mean, I, uh, listen, you know, the painkiller, the opioid painkiller industry spends, I think, the statistic is, like, seven or eight times what the gun lobby spends on lobbying in Washington, right? So, so just imagine, um, the kind of impact that you can have on the, on the legislative picture. And then you see this with, you know, with a, with a company like Purdue. You have this long period of time where all these states are trying to respond at a state level to the opioid crisis, and they're, they're, you know, they're trying to introduce new legislation to shut down pill mills or, um, you know, go after bad docs and what have you. And y- you have these legislative initiatives at a state level that get set up, and Purdue finds the right state lobbyists to go to the state capital, uh, and help neuter those bills, uh, a- a- as best, as best they can and were very successful at doing that. I mean, it is a, um... When you have a drug that's generated $35 billion in revenue, the amount of influence you can buy is just awesome.

12. 1:39:48 – 1:54:36

    Lack of accountability following the investigation and prosecution of Purdue and the Sackler family

    1. PAPeter Attia1:39:48

       So what, what happened? What was the first sort of shot across the bow? 2007. It's a little bit of a slap on the wrist. What, what led to that?

    2. PKPatrick Radden Keefe1:39:57

       [sighs] You had a, uh, a couple of investigators at a, at a small federal prosecutor's office in the Western District of Virginia who their community had been upended, uh, by OxyContin specifically. They're just, they started realizing, you know, we're getting all these pharmacy thefts, and crime is going up, and you get people OD'ing. Um, and they started investigating, and, and to them it was this kinda weird thing where they felt like, they felt like a hurricane had just, like, hit their town. And they wondered where it came from, and it came from Connecticut. Um, so they started investigating, and they, they did this really amazing investigation. They spent five years investigating Purdue. They subpoenaed millions of documents. They did, you know, huge amounts of grand jury testimony, um, and, uh, wanted to charge three senior executives at the company with felonies, the idea being that these guys were, you know, were not gonna go to jail. [laughs] Um, faced with jail time, they would flip on the Sacklers. Um, one of those federal prosecutors has said this on the record, uh, and there's another one who's confirmed for me, um, that the plan was actually to target the Sacklers if they could flip these guys. And what ended up happening was that the, um, the company sent Rudy Giuliani and Mary Jo White to kind of go over the heads of those federal prosecutors to the George W. Bush Justice Department in Washington and say, "You can't go after these guys for felonies. We need to take felonies off the table, take jail time off the table." And, uh, so they got overruled by their own bosses.

    3. PAPeter Attia1:41:48

       This was Alice Fisher and Paul McNulty.

    4. PKPatrick Radden Keefe1:41:50

       Yeah, exactly. Yeah. Um, and it- which is funny, too, 'cause it's again, th- there's, it's a little bit like that line in the, in the package insert where, in 2021, I talked to Alice Fisher and Paul McNulty and said, "Who made that decision to tell these prosecutors in the Western District of Virginia?" [laughs] And it's like-

    5. PAPeter Attia1:42:06

       They're each pointing at each other

    6. PKPatrick Radden Keefe1:42:07

       ... you know, they're, they're pointing at each other

    7. PAPeter Attia1:42:08

       Yeah

    8. PKPatrick Radden Keefe1:42:08

       Nobody would own it. Um, you would think, you know, um, all these years on, um, pretty consequential decision. You would think that somebody might take responsibility for it. But, um, but what that meant is that because they couldn't charge these guys with felonies, the guys weren't gonna flip. They just, they char- they pled to misdemeanors, so they couldn't go after the Sacklers. The company paid a $600 million fine and pled guilty to felony charges of misbranding. Um, and then it was, it was pretty much business as usual. I mean, they didn't, um, they did not slow down their marketing a jot.

    9. PAPeter Attia1:42:46

       So what changed in the last couple of years? What, what's led to the bankruptcy? And perhaps more importantly, where do we stand on this, what is it called? This non-consensual, uh-

    10. PKPatrick Radden Keefe1:43:02

        Third-party release

    11. PAPeter Attia1:43:03

        ... third-party release. Yes. This, this seems to be a very important granting on the part of a, uh, one White Plains, um, bankruptcy judge.

    12. PKPatrick Radden Keefe1:43:12

        Yeah. Robert Drain. So, um, so 2007, the company pleads guilty, and the official line after that was, "Oh, you know, we, we kinda cleaned up our act. We had a few bad apples, but everything's okay now." Um, but they didn't really change a whole lot. Um, and r- really all the senior folks, you know, but there, there, there were, the three guys who pled guilty to misdemeanors had to leave. They couldn't keep working at the company. But other than that, all the senior folks [laughs] who were involved in this stuff stayed on. Heads did not roll. Um, and, uh, Purdue kinda kept doing what it was doing. Um, in 2020, the company pled guilty to a new set of federal criminal charges, and, and the, the conduct that it pled to dated back 10 years. So if, if you imagine, right, like the, you have a company that pleads guilty in 2007, and then in theory there's like a couple years of good behavior, but then starting in about 2010, they were back to committing crimes and kept at it through 2020 when they pled guilty again. Um, and in between those two guilty pleas, what happens is that you get all these lawsuits. So some of these are private, you know, class action lawsuits, lawsuits brought by hospitals, school districts, um, cities, states. Eventually every state in the union pretty much is suing Purdue over its role in the opioid crisis. Um, and what's happening in parallel to that, which we didn't know about until fairly recently, is that the Sacklers, starting in 2007 after that guilty plea, they start quietly taking money out of the company. So they're just sort of siphoning money out, 100 million here, 100 million there. Over the course of about a decade, they take more than $10 billion out of the company. And then in, in, uh, 2018, 2019, um, I guess 2019, you have thousands of lawsuits against the company. Company's kind of on the ropes, and the family kicks the company into bankruptcy. They say the company doesn't have any money anymore, um, which is only the case because they took $10 billion out of it. But they say the company's bankrupt now, so all those lawsuits against the company have to be suspended. And they end up in this bankruptcy court in White Plains, New York. Because this is the way bankruptcy law works, they got to pick their judge. They, they, you can decide where you wanna declare bankruptcy, corporate bankruptcy. So they picked this judge who they thought would be sympathetic. Um, and where it gets really interesting is that by this point, roughly half of the states were, were not just suing the company, they were suing individual members of the family who had sat on the company's board. And there was a move by the company and the family to say, "Okay, so you've suspended all these lawsuits against the company because it's in bankruptcy, but we want you to suspend the lawsuits against the family, too, even though they haven't declared bankruptcy." And the judge did that temporarily, um, which is pretty controversial. There are states in which you're, you're not able to do that. You're not able to say to, like, the attorneys general of half of the states, "No, you cannot bring your, your lawsuit." You know, a federal bankruptcy judge in New York says to the state AG of Idaho, like, "No, you cannot bring your state-based claim." Um, it's pretty exotic, but, uh, he did. And where we are now is we're sort of in the end game where the Sacklers have made this bid, which is they want him to make that grant permanent, where he would permanently immunize them from any litigation. So the, the, the phrase for this, and it's a, it's a mouthful, is non-consensual third-party releases. Um, and this is happening in real time. Like, as you and I are talking, there's a, there's a bankruptcy trial going on with testimony, uh, but I think everybody knows how it's gonna end.

    13. PAPeter Attia1:47:26

        Why, why are we so pessimistic? Why do we, why are we pretty convinced that it's gonna, that the, um, that the ruling is gonna hold up?

    14. PKPatrick Radden Keefe1:47:35

        Because the judge has, has kinda telegraphed where he's, he's going with it, um, and because, uh, there are some states that continue to fight, but they effectively don't have the votes. So basically what you have is a situation in which the Sacklers have made a proposal to, in one fell swoop, deal with all this litigation kind of once and for all, and they're doing it in the context of this bankruptcy proceeding, where they say, "We will pay $4.5 billion of our money to remediate the opioid crisis. We'll pay it out over nine years, and we'll make no admission of wrongdoing. We'll give up our interest in Purdue, and we'll be granted one of these non-consensual third-party releases," where basically this judge gets to kind of wave his wand and say, "Nobody can ever sue you again. No state prosecutor, no private plaintiff, nobody can sue you ever again over anything having to do with OxyContin or the opioid crisis." And I think there are a lot of states that are desperate and fighting, you know, dealing with the kind of, the trillions of dollars in, in, in public costs that, that this crisis has generated. They're, they're reeling. They see $4.5 billion and they think, "I could use one-fiftieth of that," you know? Um, so they're inclined to take the deal even if they don't like it. You know, it's an interesting one because I think, I think a lot of people look at it and they feel like this wouldn't be justice. Um, to put that $4.5 billion number in, in perspective, the Sacklers still have an $11 billion fortune, and they're gonna pay it out, pay out the 4.5 over nine years. So-

    15. PAPeter Attia1:49:20

        And it's actually not linearly weighted. The majority of that-

    16. PKPatrick Radden Keefe1:49:23

        Right

    17. PAPeter Attia1:49:23

        ... payment comes at the end of time.

    18. PKPatrick Radden Keefe1:49:24

        Later.

    19. PAPeter Attia1:49:25

        So in theory, they're technically gonna come out ahead if they reasonably invest well.

    20. PKPatrick Radden Keefe1:49:31

        Yeah. I mean, I, you know, I did some, I, I had some conversations with people who, who advise high net worth families, um, and, and invest their fortunes in the, in the, you know, I think conservatively between interests and, and, and a, and a very conservative portfolio, uh, they can probably expect a, you know, a, a 5% return on that $11 billion fortune. And if that's the case, they never have to touch their principal. Yeah. I mean, this will not, um- Uh, again, in absolute terms, it's a lot of money. Um, but it's, it's, I don't think commensurate to the damage, and I think ultimately it'll be a pretty good deal for the Sacklers. But I think that's, that's how it's gonna shake out.

    21. PAPeter Attia1:50:12

        Now, do you think that this accomplishes anything else? So, um, no amount of money is gonna bring back a loved one. You know, I, I have, um, I have several patients whose lives have been directly impacted by this, whose, whose children have overdosed. Um, so, so kids that became addicted to prescription pain pills and, um, you know, in one situation, um, one of the, one of the kids was clean for a number of months, if not a year, was at a party. Someone suggested he try a pill. It turned out to be laced with fentanyl, and you know how that story ends tragically. So no amount of money's gonna fix that, and so whether the Sacklers have to give four and a half billion or forfeit every dollar they've ever made and will make in perpetuity, that never brings back a life. So really it's about two things, isn't it? It's sort of about how much can be fixed today with money, 'cause maybe some things can be fixed with money, some things can't. I guess three things. Is justice being served? And the third thing would be, is this creating a deterrent for another entity in the future to be a little more careful with what they do? So let's talk about the latter. Do you think that this will create a sufficient enough deterrent? A- and not just this. I mean, if you look at, what was that other company? In- Insys or something like that.

    22. PKPatrick Radden Keefe1:51:47

        Insys, yeah.

    23. PAPeter Attia1:51:48

        Yeah.

    24. PKPatrick Radden Keefe1:51:48

        Well, Ins- Insys was different because Insys people went to jail.

    25. PAPeter Attia1:51:51

        Yeah. So, so, so when you look at the totality of these things, do you think that at least for the foreseeable future, the legal/illicit drug market is, uh, you know, kind of on, on, on notice?

    26. PKPatrick Radden Keefe1:52:06

        I do and I don't. I mean, I think that the, um... L- look, in some ways this, this kind of, this fits into a larger trend that we've seen happening over the last, uh, 10 or 15 years, um, sort of since the days of Enron and WorldCom, which is that there's a, there's a pronounced disinclination, this is across political parties, to, uh, bring criminal charges and, and, and, and jail time into the equation when it comes to corporate executives acting within their role, even if the conduct is criminal. So you have this kind of bizarre thing with Purdue Pharma where when the company pled guilty for a second time in 2020, there were no individual executives even named. So as I say in the book, it's like it, it's like it's a driverless car. I mean, h- how is it that the company could commit federal crimes if there's no individuals who can be-

    27. PAPeter Attia1:53:02

        [laughs]

    28. PKPatrick Radden Keefe1:53:02

        ... identified as having committed crimes? It doesn't make any sense, but I think it's, it's sort of expressive of or reflective of, um, the general posture of, of the Justice Department and, and, um, and our whole sort of system of justice broadly speaking, which is we don't really, um... It, it, it's really the exception when a corporate executive ends up doing jail time, as we saw in Insys. And the Insys case is kind of [laughs] particularly extreme. Insys is like, you know, everything you see in the Purdue story, but just like dialed up to 11. I think there are a bunch of reasons why you saw jail time in the Insys case and you don't in the, in the Purdue context or in changing-

    29. PAPeter Attia1:53:44

        What was the CEO? Was it Kumar? Wasn't that his last name? Something Kumar.

    30. PKPatrick Radden Keefe1:53:48

        Yeah, I'm blanking on his name, but yes.
13. 1:54:36 – 2:04:12

    Legacy of the Sackler family and their disconnect from reality

    1. PKPatrick Radden Keefe1:54:36

       you know, you look at the Sacklers, right? It's like you, you take $10 billion out of a company during a period of time when it's committing crimes. You're gonna have to give back four point five billion. Do you do it? You know? Do you, do you... You look at that fact pattern. You take, you, you got a company. Company commits crimes. You own the company. You're on the board of the company. Uh, you're never gonna go to jail. You're never gonna get charged with any crimes. You will have to give back four point five billion, but you can do it over nine years. Do you do it? I mean, I could probably go out on the street and find you some people who would say, "Hell yeah, sign me up." Um, for the Sacklers, I think, you know, the real costs are gonna be reputational, and it's hard to measure that.

    2. PAPeter Attia1:55:29

       Y- yeah, that's, that, that, that's the thing that... I mean, you would have to argue that are they any different from O.J. Simpson?

    3. PKPatrick Radden Keefe1:55:41

       You mean in terms of the, the notion that everybody knows.

    4. PAPeter Attia1:55:45

       Yeah. Like, I mean, O.J. Simpson commits this completely heinous, graphic, premeditated, violent act in front of the world, and if not for a technicality, effectively, you know, and a racist cop gets off, right?

    5. PKPatrick Radden Keefe1:56:05

       Right

    6. PAPeter Attia1:56:05

       But I don't think the world's ever really forgiven him, right? I mean, I, my guess is he probably is being basically socially punished, uh, for the rest of his life, and rightfully so. Um, is justice served? No, presumably not. He should be in jail, but nevertheless. So the blood of two people is on O.J. Simpson's hands. The blood of how many people is on the Sacklers' hands? Conservatively.

    7. PKPatrick Radden Keefe1:56:32

       Right, many more.

    8. PAPeter Attia1:56:32

       What would be the most conservative estimate, right? [laughs]

    9. PKPatrick Radden Keefe1:56:36

       I mean, it's so hard to say, right? Because the thing is you can, you can, what, you know, do you look just at people who've OD'd on OxyContin? And of course they would say, again, with that parsing, they would say, "Ah, yes, but you know, there were other drugs in their systems."

    10. PAPeter Attia1:56:49

        Yeah.

    11. PKPatrick Radden Keefe1:56:50

        Um-

    12. PAPeter Attia1:56:50

        My point is, of the half a million people who have died in the last two decades, I'm willing to acknowledge that some sub- some subset, maybe a small subset of those people-

    13. PKPatrick Radden Keefe1:57:02

        Right

    14. PAPeter Attia1:57:02

        ... the blood is on the hands of this family, and work like yours has really brought that to light. Um, and it just, I just wonder what the rest of their lives look like, and will this be basically forgotten about, and will the next generation of Sacklers carry no shame for this, or will this be something that forever makes people in polite company a bit embarrassed to be around them?

    15. PKPatrick Radden Keefe1:57:30

        Uh, it's, it's funny, I mean, I think, I think both of the last two things you said are, are going to be the case. I think the, um, I think people will forever be embarrassed to be around them. I think the name is toxic, and it's, you know, it's, it's coming down off of institutions. I think it'll come down off of more institutions. I think the, the family, uh, isn't happy about that. Um, but I also don't know that any of them feel any shame. I mean, there's this kind of... One of the things that's been so revealing to me is, um, it's funny, there's an analogy that I, I don't draw in the book in any explicit way deliberately, but it was one that I thought about a lot is, you know, I was writing this book in the last years of the Trump presidency. And, um, you know, one sense in which the Sackler situation I think was a little bit similar to Trump's, um, and it, it, it's a sense in which I'm almost sympathetic in both cases, is if you're a billionaire, and you're surrounded by advisors, and lawyers, and PR people, and all these people whose livelihood depends on keeping you happy. And I feel as though th- there is a kind of, um, heightened danger of delusion, of you just getting out of touch with reality, and it probably starts in small ways, right? That you, you tell a joke and everybody in the room laughs. Um, but then you can y- y- you know, so initially you're just like kind of a millimeter or two off track in terms of the, the fidelity of your perceptions of the world. Um, but then the, the longer you go, the further off course you get, and what you saw with Trump, what you also see with the Sacklers, is that there are people in the mix. I mean, I've talked to people who a decade ago said to the family, "What if you took some of this philanthropic money that you give to art museums and started a foundation dedicated to, uh, s- the study of addiction, um, you know, redressing the opioid crisis?" Uh, people who were making, you know, frankly a cynical argument, but saying, "Just purely in terms of the optics here, um, you should make some gesture, uh, recognizing that there's a problem and that people think that you're responsible for it." And those people were always sidelined and fired, right? And the people who end up in the kind of inner circle are the ones who say, "You are just terribly misunderstood. All these people don't understand you. You know, the, the press, the public, the people making jokes on The Late Show, uh, the attorneys general of every single state, you know, all these members of Congress who keep condemning you, all these studies that are done about OxyContin and its legacy. It's all just a big misunderstanding. You never did anything wrong." And what's been astonishing to me is they, they, they tend to pretty uniformly feel that way, the family members.

    16. PAPeter Attia2:00:40

        Yeah, that's one of the things that surprised me about your book is you had to do all of this without actually talking to anyone in that family. And when you think about how many children the three Sackler brothers had, and how many children they had, and how many spouses they have, like, that's a pretty good list of people who could have come forth and said something to you, even off the record or on background. And yet, I don't, I don't think that happened, did it?

    17. PKPatrick Radden Keefe2:01:10

        No, I mean, I, I, l- listen, my assumption from the beginning had been that there must be some apostate. You know, there must be some third-generation Sackler who, who was the, who w- looks around and, you know, nevermind my writing, right? It's like they read The New York Times, they read the LA Times, they read Sam Quinones' book, Dreamland, and they say, "Jeez, you know, I'm a little-"

    18. PAPeter Attia2:01:33

        Yeah, this is blood money.

    19. PKPatrick Radden Keefe2:01:34

        "I'm a little-"

    20. PAPeter Attia2:01:34

        My trust fund is-

    21. PKPatrick Radden Keefe2:01:35

        "I'm a little uncomfortable with this."

    22. PAPeter Attia2:01:36

        My trust fund is blood money.

    23. PKPatrick Radden Keefe2:01:37

        Yeah.

    24. PAPeter Attia2:01:37

        Yeah.

    25. PKPatrick Radden Keefe2:01:37

        Right. Let me, let me, you know, I don't need this. I'm gonna turn my, turn my back on it. Couldn't find one. And one of the more revealing documents I got my hands on was this, um, it's a WhatsApp log. It's like a chat log from the m- the heirs of Mortimer Sackler. This came out in the context of the bankruptcy proceeding, where they all talk over the course of a couple of years, um, all these different family members, siblings, cousins. And they're talking about, you know, their problems and how do you deal with it, and the litigation and the bad PR and, and what's the right strategy and, um, it's this private channel. Uh, and there's nobody, nobody who at any point says, "You know, geez, maybe our critics have a point," or like, "Maybe we should ask some tough questions." Um, instead it's this pretty lockstep feeling of persecution. And in fact, I mean, sometimes when you read their private correspondence, the way they talk amongst themselves, at times it feels, it feels as though in their minds, like the real victims of the opioid crisis are the Sackler family.

    26. PAPeter Attia2:02:49

        That's amazing.

    27. PKPatrick Radden Keefe2:02:51

        It is.

    28. PAPeter Attia2:02:51

        That's more amazing to me than the indignant response that is seen publicly.

    29. PKPatrick Radden Keefe2:02:57

        Mm-hmm.

    30. PAPeter Attia2:02:58

        It's that even privately there's no awareness.
14. 2:04:12 – 2:07:46

    Patrick’s views on the regulation and use of pain management drugs

    1. PAPeter Attia2:04:13

       I know you've spoken about how you also hear from basically two groups of people, right? So you hear a lot from exactly what you've just said, the, the, the, the family members or friends of, of, of people who themselves have become addicted or who more tragically have lost those. But you also seem to hear from people saying, you know, your work is potentially threatening to the supply of pain medication to people like me who genuinely and legitimately need it, which of course is, is not your intention. Um, but you seem to be sensitive to that, and you seem to understand that there's a fine line here and an overreaction, uh, or an overcorrection that would limit the supply of or access of patients who do need pain medication to it would be, um, an unintended consequence of this work. So do you get a sense that that is actually happening?

    2. PKPatrick Radden Keefe2:05:06

       Ah, yes. I mean, I think that the, um, uh, there is a definite sense in which the pendulum has swung back, um, and in which a lot of doctors are, um, less likely to prescribe these drugs in the first place, more likely to prescribe, you know, shorter courses at lower doses. I, I think a lot of that is, is a good thing ultimately. Um, there are many, uh, chronic pain patients who are very fearful and are, you know, I, I certainly get emails from people talking about how they're, they're just fearful that their, um, that their, their supply, uh, of this drug, you know, these drugs, I'm not just talking about OxyContin here, but, but, but prescription opioid painkillers broadly, um, that they count on in order to function in life, um, is, is really jeopardized by these kind of changing currents in terms of the way in which, um, people perceive, uh, these drugs. And it, it's, it's, it's an incredibly difficult thing. I mean, I, I, um, I am very sympathetic to this. I, I, I certainly don't wanna see people who use these drugs stigmatized, whether they use them legally or illegally. I tend to be, to be pretty sympathetic with people. I'm also not a, a prohibitionist. You know, I don't, um, given all my work on, on illegal drugs, I tend not to think that, that drug prohibition is the way to go. Uh, people certainly make arguments that if you cut off pain patients, um, uh, and force, you know, do kind of rapid forced taper and what have you, that that might actually drive people onto the black market and become, you know, m- more unsafe, that that might be part of what's driving the opioid crisis. Um, where I balk at, at, at that kind of, uh, note, and this sort of goes back to the thing I said to you at, at the outset, is, um, the suggestion that I shouldn't write about the Sacklers and their culpability because there might be some sort of second or third order consequence of that, um, or, or that my, my kind of focus is in the wrong place. And, and there I'm not gonna, um, you know, I'm gonna, I'm gonna write the books that I wanna write and the articles that I wanna write. Um, I, I find it's very often the case that people who are sort of telling me that I shouldn't be doing these things, generally speaking, haven't read the book, um, you know, haven't really engaged with the particulars all

15. 2:07:46 – 2:21:59

    The difficult path forward

    1. PKPatrick Radden Keefe2:07:46

       that much. But, um, but yeah, look, I, I do hear from, from, um, pain patients quite often, and I think this has been a, a sort of an agonizing period for them because, um, from where I sit, the problem was not that a drug like OxyContin shouldn't have been produced or made available to pain patients. It was all in the decision to do two things. One was dramatically expand the universe of people who should be taking it, and the other was, uh, I think pretty systematically play down the risks so that there's a kind of dishonesty with the consumer and with- with physicians, uh, about what the dangers are. Um, uh, you know, I don't go from that to any sense that these drugs should not be available at all. There are some, some who do, some doctors who do. Um, but I don't, I sort of don't feel the need to, to, to go there myself. I'm, I'm pretty squarely focused on the origins of the crisis and, um, and some, some pretty unambiguous wrongs, uh, perpetrated by Purdue and the Sacklers.

    2. PAPeter Attia2:08:49

       So if, if the Sacklers represent a cancer, right, that cancer has largely been excised, right? The Sacklers themselves are no longer going to be a part of this dilemma. But unfortunately, the cancer metastasized for, before it was excised. So as you point out, we still have an opioid crisis, and in fact, it doesn't seem to be showing any signs of abatement. In fact-

    3. PKPatrick Radden Keefe2:09:13

       On the contrary

    4. PAPeter Attia2:09:14

       ... last year, we saw more people die of opioid overdose than any other cause of accidental death, which is actually a staggering statistic when you consider how many people die in car accidents, how many people die of, uh, gunshot wounds.

    5. PKPatrick Radden Keefe2:09:31

       Mm-hmm.

    6. PAPeter Attia2:09:32

       So in that sense, your work has been a success, and the work of all the people you've written about who have finally brought a modicum of justice to at least the initial perpetrators of this, but what does the path forward look like? Like, what will it take to actually address this crisis?

    7. PKPatrick Radden Keefe2:09:55

       Yeah. I mean, you know, this'll sound like a cop-out, but, but in some ways I, I'm so overwhelmed by that question. I think anybody would be. Um, you know, the, the way in which I've grappled with that is to kind of take this, this small piece of it that I can focus on and understand, and for me, in, in some ways, it's kind of, you know, looking at the origin story of the crisis really more than where we are now. Um, the numbers are staggering. Uh, as you say, they're getting worse. Um, the sense in which I, I feel as though the Sacklers are not absolved by the fact that this is today a heroin and fentanyl crisis is the sense in which there are many, many people who I think would never have taken heroin or fentanyl in the first in- instance that, that, that started on prescription opioids like OxyContin. Um, but of course, you know, from the vantage point of today [laughs] , like I'd, I'd rather people be abusing OxyContin than abusing fentanyl, right, or heroin that's laced with who knows what. Um, the, um... It is a very, very scary situation. I feel as though, um, we need far more resources than we have. I mean, I, I, I think it's a problem that needs to be resourced. I think treatment is very often not available to people. I think there's still a huge amount of, um, of stigma associated with, uh, with the abuse of an addiction when it comes to these types of drugs. Um, and anything we can do to diminish that stigma, I think, you know, medically assisted treatment, which I, I, I think there are still some for whom that's a kind of a scary concept, and I, I, I think it's a, it's, it's one that, um, should be, uh, should be adopted and embraced and, and, and not cause the, um, the consternation that it does for some. Um, but I think it's a huge national crisis, and in a strange way, I feel as though were it not for COVID, it's not that the problem would've been solved, but I feel as though the, um... Just prior to COVID, there was a sense in which I, you know, it's tricky 'cause it was the Trump administration, but the, um, but I think there was sort of a recognition that we need a major national strategy to deal with this. It is out of control, um, and killing people in vast numbers, and we need to, uh, to kind of, you know, have all ideas on the table and be strategic and, and r- and resource the solution. Um, and then COVID came along, and, um, there just wasn't really the, the bandwidth, right, or the oxygen in the room to have that conversation. But, but when we neglect the problem, as we have during COVID for, for, uh, you know, just purely in terms of the triage over the last 18 months, you see what happens.

    8. PAPeter Attia2:12:53

       Are you optimistic that 10 years from now things will be different?

    9. PKPatrick Radden Keefe2:13:04

       I mean, I have to be just because I'm, I'm, believe it or not, after this, [laughs] after this grim conversation, I'm, I'm fundamentally an optimist, uh, about a lot of things. I, I, I have to believe we will learn and we'll sort of find a way out of this. Um, but it's hard, and I think the hardest thing, in a way, is, you know, I've, I've, I've had many of these conversations, and it sound like, sounds like you have, too. You mentioned, you know, the patient who, who had a family member who, um, who actually managed to stop using and seemed as though they'd moved on and then went to a party, um, and relapse is such an issue with these drugs, right? That the, um, when you, when you talk to people who've, who've sort of achieved, you know, th- they've, they've, they've found their way out of the woods, often the thing that's so striking to me is that there's a kind of, um, there's a sort of fragility to it, you know? Um, they're always talking in the, in the, in the present tense. There's this sense that kind of every day is a battle, um, and that's what worries me, I think, about, about the idea of us kind of 10 years from now, right? Is that, um, on a kind of very micro level for the individual who is struggling with addiction, um, there's that sense in which it's like each tentative step, you just never know when you're gonna get pulled back in, um- And so on a kind of macro level nationally, uh, I, I worry that there may be a similar danger.

    10. PAPeter Attia2:14:40

        Yeah. I, I, I worry about the, the, the sort of impact of what it takes to escape the gravitational pull of an environment that facilitated the use. Um, I did my residency at Hopkins, which is in inner-city Baltimore, and, um, even 20 years ago was, was probably a leading indicator for how bad, uh, heroin use could get. Um, and I remember, you know, we would take care of a lot of patients who had, um, abscesses and all sorts of, you know, infections and cellulitis and things like that from IV drug use, and sometimes these infections themselves were life-threatening. So it wasn't just the overdose on the drug. It was the repeated use of a dirty needle or a needle that gets broken inside the arm and gets infected. And, you know, so you would take care of these patients, and you always wished them the best when they left, but you were, you were really... In the back of your mind, you knew you were gonna see them again because even though for the five days that they were in the hospital they were not using any drug and they, with the total clarity of the thought that they had, realized how lucky they were to get this second chance, they were still going back into the same environment that brought them into the hospital in the first place. And w- we used to sort of say to ourselves, like, "You know, the only way this person's not coming back is if they get a whole new group of friends." Like, in fact, the best thing you could do for this person is get them out of inner-city Baltimore, right? Like, they can't go back to the row home they came from.

    11. PKPatrick Radden Keefe2:16:29

        Mm.

    12. PAPeter Attia2:16:29

        Now, that might sound like a very extreme example, right? Well, come on, inner-city Baltimore. I mean, you're talking about a crack house, da, da, da, da, da. But is it really any different for a college kid who's trying to desperately get off, you know, the, the transition from, you know, oxycodone to fentanyl, and this is being done in a dorm room or at a party or something like that, and it's their friends, and they deci- you know, they, they manage to, you know, again, pull out of the grip of that, but they find themselves at another party in three months. I mean, it's really difficult. That, that's the part that, that concerns me is if, i- is it's hard to do this one person at a time.

    13. PKPatrick Radden Keefe2:17:08

        Yeah. Yeah. And, um, and it's, uh... Again, I mean, I, I think I... It's, it's funny. I, I kind of come back to the, you know, that idea of undertow and, and e- even you telling your own story about, um, about your experience with OxyContin. I, I, um, I think the big thing that comes home to me is just that the... You know, these things are, these substances are, are, they have an awesome power, and, um, and it, and that's, um, compounded by all of the kind of atmospheric, social, sort of situational things you were talking about. Um, but just having talked to a lot of families over the years who've, who've dealt with this, and they, you know, they, they thought they were out of the woods, and then they weren't, um, I, I think you're right. Like, i- in, in any one individual life, and even somebody who actually has a really supportive, you know, they've got a whole support system there, and, and in some instances, you know, in many instances there are people who, who, um, they don't have the resources, uh, for the appropriate treatment. But in many instances there, instances there are people who do, right? Who, who throw resources at the problem. Um, and it's not enough. It's not adequate. Uh, so I, I think that the, um... I just think we should all be sort of humble and, and m- and mindful in the face of the tremendous kind of potency and power, uh, that, that, that's on the other side of this problem.

    14. PAPeter Attia2:18:47

        Yeah. Well, Patrick, thank you very much for, um, first and foremost, for your, for your book and your investigation, which I think has brought to light a lot of things that, that probably could have easily gotten ignored or swept away. I mean, it's, it's true that dur- you know, during these proceedings a lot of documents are brought into the public light, but that's, that's only half the battle. That's the easy half. The hard part is actually going through them and extracting what the story is, and, and you've, you've done a better job of that with respect to this important part of the story than anybody else. But also thank you for making time. I know this is, uh-

    15. PKPatrick Radden Keefe2:19:21

        Of course

    16. PAPeter Attia2:19:21

        ... I imagine as an author you must get tired of having to do interviews on the same topic. But, um, I, I really appreciate it.

    17. PKPatrick Radden Keefe2:19:27

        Oh, but this one was so, it was really, really in-depth and, and, uh, yeah, I very much enjoyed it. It, it was a great conversation. Thank you.

    18. PAPeter Attia2:19:33

        Thank you, Patrick. [upbeat music] Thank you for listening to this week's episode of The Drive. If you're interested in diving deeper into any topics we discuss, we've created a membership program that allows us to bring you more in-depth exclusive content without relying on paid ads. It's our goal to ensure members get back much more than the price of the subscription. Now, to that end, membership benefits include a bunch of things. One, totally kickass comprehensive podcast show notes that detail every topic, paper, person, thing we discuss on each episode. The word on the street is nobody's show notes rival these. Monthly AMA episodes, or Ask Me Anything episodes, hearing these episodes completely. Access to our private podcast feed that allows you to hear everything without having to listen to spiels like this. The Qualies, which are a super short podcast that we release every Tuesday through Friday highlighting the best questions, topics, and tactics discussed on previous episodes of The Drive. This is a great way to catch up on previous episodes without having to go back and necessarily listen to every one. Steep discounts on products that I believe in but for which I'm not getting paid to endorse, and a whole bunch of other benefits that we continue to trickle in as time goes on. If you wanna learn more and access these member-only benefits, you can head over to peterattiamd.com/subscribe. You can find me on Twitter, Instagram, and Facebook, all with the ID peterattiamd. You can also leave us a review on Apple Podcast or whatever podcast player you listen on. This podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. No doctor-patient relationship is formed. The use of this information and the materials linked to this podcast is at the user's own risk. The content on this podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Users should not disregard or delay in obtaining medical advice from any medical condition they have, and they should seek the assistance of their healthcare professionals for any such conditions. Finally, I take conflicts of interest very seriously. For all of my disclosures and the companies I invest in or advise, please visit peterattiamd.com/about where I keep an up-to-date and active list of such companies. [upbeat music]

Episode duration: 2:21:59