The Sackler dynasty’s ruthless marketing of painkillers has generated billions of dollars—and millions of addicts.

The north wing of the Metropolitan Museum of Art is a vast, airy enclosure featuring a banked wall of glass and the Temple of Dendur, a sandstone monument that was constructed beside the Nile two millennia ago and transported to the Met, brick by brick, as a gift from the Egyptian government. The space, which opened in 1978 and is known as the Sackler Wing, is also itself a monument, to one of America’s great philanthropic dynasties. The Brooklyn-born brothers Arthur, Mortimer, and Raymond Sackler, all physicians, donated lavishly during their lifetimes to an astounding range of institutions, many of which today bear the family name: the Sackler Gallery, in Washington; the Sackler Museum, at Harvard; the Sackler Center for Arts Education, at the Guggenheim; the Sackler Wing at the Louvre; and Sackler institutes and facilities at Columbia, Oxford, and a dozen other universities. The Sacklers have endowed professorships and underwritten medical research. The art scholar Thomas Lawton once likened the eldest brother, Arthur, to “a modern Medici.” Before Arthur’s death, in 1987, he advised his children, “Leave the world a better place than when you entered it.”

Mortimer died in 2010, and Raymond died earlier this year. The brothers bequeathed to their heirs a laudable tradition of benevolence, and an immense fortune with which to indulge it. Arthur’s daughter Elizabeth is on the board of the Brooklyn Museum, where she endowed the Elizabeth A. Sackler Center for Feminist Art. Raymond’s sons, Richard and Jonathan, established a professorship at Yale Cancer Center. “My father raised Jon and me to believe that philanthropy is an important part of how we should fill our lives,” Richard has said. Marissa Sackler, the thirty-six-year-old daughter of Mortimer and his third wife, Theresa Rowling, founded Beespace, a nonprofit “incubator” that supports organizations like the Malala Fund. Sackler recently told W that she finds the word “philanthropy” old-fashioned. She considers herself a “social entrepreneur.”

When the Met was originally built, in 1880, one of its trustees, the lawyer Joseph Choate, gave a speech to Gilded Age industrialists who had gathered to celebrate its dedication, and, in a bid for their support, offered the sly observation that what philanthropy really buys is immortality: “Think of it, ye millionaires of many markets, what glory may yet be yours, if you only listen to our advice, to convert pork into porcelain, grain and produce into priceless pottery, the rude ores of commerce into sculptured marble.” Through such transubstantiation, many fortunes have passed into enduring civic institutions. Over time, the origins of a clan’s largesse are largely forgotten, and we recall only the philanthropic legacy, prompted by the name on the building. According to Forbes, the Sacklers are now one of America’s richest families, with a collective net worth of thirteen billion dollars—more than the Rockefellers or the Mellons. The bulk of the Sacklers’ fortune has been accumulated only in recent decades, yet the source of their wealth is to most people as obscure as that of the robber barons. While the Sacklers are interviewed regularly on the subject of their generosity, they almost never speak publicly about the family business, Purdue Pharma—a privately held company, based in Stamford, Connecticut, that developed the prescription painkiller OxyContin. Upon its release, in 1995, OxyContin was hailed as a medical breakthrough, a long-lasting narcotic that could help patients suffering from moderate to severe pain. The drug became a blockbuster, and has reportedly generated some thirty-five billion dollars in revenue for Purdue.

But OxyContin is a controversial drug. Its sole active ingredient is oxycodone, a chemical cousin of heroin which is up to twice as powerful as morphine. In the past, doctors had been reluctant to prescribe strong opioids—as synthetic drugs derived from opium are known—except for acute cancer pain and end-of-life palliative care, because of a long-standing, and well-founded, fear about the addictive properties of these drugs. “Few drugs are as dangerous as the opioids,” David Kessler, the former commissioner of the Food and Drug Administration, told me.

Purdue launched OxyContin with a marketing campaign that attempted to counter this attitude and change the prescribing habits of doctors. The company funded research and paid doctors to make the case that concerns about opioid addiction were overblown, and that OxyContin could safely treat an ever-wider range of maladies. Sales representatives marketed OxyContin as a product “to start with and to stay with.” Millions of patients found the drug to be a vital salve for excruciating pain. But many others grew so hooked on it that, between doses, they experienced debilitating withdrawal.

Since 1999, two hundred thousand Americans have died from overdoses related to OxyContin and other prescription opioids. Many addicts, finding prescription painkillers too expensive or too difficult to obtain, have turned to heroin. According to the American Society of Addiction Medicine, four out of five people who try heroin today started with prescription painkillers. The most recent figures from the Centers for Disease Control and Prevention suggest that a hundred and forty-five Americans now die every day from opioid overdoses.

Andrew Kolodny, the co-director of the Opioid Policy Research Collaborative, at Brandeis University, has worked with hundreds of patients addicted to opioids. He told me that, though many fatal overdoses have resulted from opioids other than OxyContin, the crisis was initially precipitated by a shift in the culture of prescribing—a shift carefully engineered by Purdue. “If you look at the prescribing trends for all the different opioids, it’s in 1996 that prescribing really takes off,” Kolodny said. “It’s not a coincidence. That was the year Purdue launched a multifaceted campaign that misinformed the medical community about the risks.” When I asked Kolodny how much of the blame Purdue bears for the current public-health crisis, he responded, “The lion’s share.”

Although the Sackler name can be found on dozens of buildings, Purdue’s Web site scarcely mentions the family, and a list of the company’s board of directors fails to include eight family members, from three generations, who serve in that capacity. “I don’t know how many rooms in different parts of the world I’ve given talks in that were named after the Sacklers,” Allen Frances, the former chair of psychiatry at Duke University School of Medicine, told me. “Their name has been pushed forward as the epitome of good works and of the fruits of the capitalist system. But, when it comes down to it, they’ve earned this fortune at the expense of millions of people who are addicted. It’s shocking how they have gotten away with it.”

“Dr. Sackler considered himself and was considered to be the patriarch of the Sackler family,” a lawyer representing Arthur Sackler’s children once observed. Arthur was a gap-toothed, commanding polymath who trained under the Dutch psychoanalyst Johan H. W. van Ophuijsen, whom Sackler proudly described as “Freud’s favorite disciple.” Arthur and his brothers, the children of Jewish immigrants from Galicia and Poland, grew up in Brooklyn during the Depression. All three attended medical school, and worked together at the Creedmoor Psychiatric Center, in Queens, collectively publishing some hundred and fifty scholarly papers. Arthur became fascinated, he later explained, by the ways that “nature and disease can reveal their secrets.” The Sacklers were especially interested in the biological aspects of psychiatric disorders, and in pharmaceutical alternatives to mid-century methods such as electroshock therapy and psychoanalysis.

But the brothers made their fortunes in commerce, rather than from medical practice. They shared an entrepreneurial bent. As a teen-ager, Mortimer became the advertising manager of his high-school newspaper, and after persuading Chesterfield to place a cigarette ad he got a five-dollar commission—a lot of money at a time when, he later said, “even doctors were selling apples in the streets.” In 1942, Arthur helped pay his medical-school tuition by taking a copywriting job at William Douglas McAdams, a small ad agency that specialized in the medical field. He proved so adept at this work that he eventually bought the agency—and revolutionized the industry. Until then, pharmaceutical companies had not availed themselves of Madison Avenue pizzazz and trickery. As both a doctor and an adman, Arthur displayed a Don Draper-style intuition for the alchemy of marketing. He recognized that selling new drugs requires a seduction of not just the patient but the doctor who writes the prescription.

Sackler saw doctors as unimpeachable stewards of public health. “I would rather place myself and my family at the judgment and mercy of a fellow-physician than that of the state,” he liked to say. So in selling new drugs he devised campaigns that appealed directly to clinicians, placing splashy ads in medical journals and distributing literature to doctors’ offices. Seeing that physicians were most heavily influenced by their own peers, he enlisted prominent ones to endorse his products, and cited scientific studies (which were often underwritten by the pharmaceutical companies themselves). John Kallir, who worked under Sackler for ten years at McAdams, recalled, “Sackler’s ads had a very serious, clinical look—a physician talking to a physician. But it was advertising.” In 1997, Arthur was posthumously inducted into the Medical Advertising Hall of Fame, and a citation praised his achievement in “bringing the full power of advertising and promotion to pharmaceutical marketing.” Allen Frances put it differently: “Most of the questionable practices that propelled the pharmaceutical industry into the scourge it is today can be attributed to Arthur Sackler.”

Advertising has always entailed some degree of persuasive license, and Arthur’s techniques were sometimes blatantly deceptive. In the nineteen-fifties, he produced an ad for a new Pfizer antibiotic, Sigmamycin: an array of doctors’ business cards, alongside the words “More and more physicians find Sigmamycin the antibiotic therapy of choice.” It was the medical equivalent of putting Mickey Mantle on a box of Wheaties. In 1959, an investigative reporter for The Saturday Review tried to contact some of the doctors whose names were on the cards. They did not exist.

During the sixties, Arthur got rich marketing the tranquillizers Librium and Valium. One Librium ad depicted a young woman carrying an armload of books, and suggested that even the quotidian anxiety a college freshman feels upon leaving home might be best handled with tranquillizers. Such students “may be afflicted by a sense of lost identity,” the copy read, adding that university life presented “a whole new world . . . of anxiety.” The ad ran in a medical journal. Sackler promoted Valium for such a wide range of uses that, in 1965, a physician writing in the journal Psychosomatics asked, “When do we not use this drug?” One campaign encouraged doctors to prescribe Valium to people with no psychiatric symptoms whatsoever: “For this kind of patient—with no demonstrable pathology—consider the usefulness of Valium.” Roche, the maker of Valium, had conducted no studies of its addictive potential. Win Gerson, who worked with Sackler at the agency, told the journalist Sam Quinones years later that the Valium campaign was a great success, in part because the drug was so effective. “It kind of made junkies of people, but that drug worked,” Gerson said. By 1973, American doctors were writing more than a hundred million tranquillizer prescriptions a year, and countless patients became hooked. The Senate held hearings on what Edward Kennedy called “a nightmare of dependence and addiction.”

While running his advertising company, Arthur Sackler became a publisher, starting a biweekly newspaper, the Medical Tribune, which eventually reached six hundred thousand physicians. He scoffed at suggestions that there was a conflict of interest between his roles as the head of a pharmaceutical-advertising company and the publisher of a periodical for doctors. But in 1959 it emerged that a company he owned, MD Publications, had paid the chief of the antibiotics division of the F.D.A., Henry Welch, nearly three hundred thousand dollars in exchange for Welch’s help in promoting certain drugs. Sometimes, when Welch was giving a speech, he inserted a drug’s advertising slogan into his remarks. (After the payments were discovered, he resigned.) When I asked John Kallir about the Welch scandal, he chuckled, and said, “He got co-opted by Artie.”

In 1952, the Sackler brothers bought a small patent-medicine company, Purdue Frederick, which was based in Greenwich Village and made such unglamorous staples as laxatives and earwax remover. According to court documents, each brother would control a third of the company, but Arthur, who was occupied with his publishing and advertising ventures, would play a passive role. The journalist Barry Meier, in his 2003 book, “Pain Killer: A ‘Wonder’ Drug’s Trail of Addiction and Death,” remarks that Arthur treated his brothers “not as siblings but more like his progeny and understudies.” Now Raymond and Mortimer, who became joint C.E.O.s, had a company of their own.

In the early sixties, Estes Kefauver, a Tennessee senator, chaired a subcommittee that looked into the pharmaceutical industry, which was growing rapidly. Kefauver, who had previously investigated the Mafia, was especially intrigued by the Sackler brothers. A memo prepared by Kefauver’s staff noted, “The Sackler empire is a completely integrated operation in that it can devise a new drug in its drug development enterprise, have the drug clinically tested and secure favorable reports on the drug from the various hospitals with which they have connections, conceive the advertising approach and prepare the actual advertising copy with which to promote the drug, have the clinical articles as well as advertising copy published in their own medical journals, [and] prepare and plant articles in newspapers and magazines.” In January, 1962, Arthur travelled to Washington to testify before Kefauver’s subcommittee. A panel of senators assailed him with pointed questions, but he was a formidable interlocutor—slippery, aloof, and impeccably prepared—and no senator landed a blow. At one point, Sackler caught Kefauver in an error and said, “If you personally had taken the training that a physician requires to get a degree, you would never have made that mistake.” Quizzed about his promotion of a cholesterol drug that had many side effects, including hair loss, Sackler deadpanned, “I would prefer to have thin hair to thick coronaries.”

As the Sacklers grew wealthy, they became patrons of the arts. In 1974, the brothers gave the Met three and a half million dollars, enabling the construction of the wing housing the Temple of Dendur. Mortimer used the space for a lavish birthday party. The cake was in the shape of the Great Sphinx, but its face had been replaced with Mortimer’s.

In April, 1987, when Arthur Sackler was seventy-three, he demanded that his third wife, Gillian, account for all their household expenditures. He dictated a terse memo: “I am determined to take command of all situations for which I personally and my estate bear the ultimate obligation.” A month later, he had a heart attack, and died. The family gathered for a fond memorial service at the Met, but Arthur’s children fought bitterly with Gillian, and sparred with Mortimer and Raymond, over the estate. They accused Gillian of trying to steal their inheritance, and of being “inspired variously by greed, malice, or vindictiveness toward her stepchildren.” According to the minutes of a family meeting, Arthur’s daughter Elizabeth suggested that he had hidden the true worth of some family investments, “because he didn’t want Morty and Ray to think they were more valuable.” A family lawyer told the children, “There were no absolutely white lilies here on either side.”

Arthur’s descendants still owned a third of Purdue Frederick, and Mortimer and Raymond were interested in buying the stake. The company, which had moved to Connecticut and would eventually change its name to Purdue Pharma, had made a great deal of money under their stewardship. But such riches were about to seem paltry. By the time the brothers made their bid, Purdue was already developing a new drug: OxyContin.

Humans have cultivated the opium poppy for five thousand years. The father of medicine, Hippocrates, recognized the therapeutic properties of the plant. But even in the ancient world people understood that the benevolent powers of this narcotic were offset by the perils of addiction. In his 1996 book, “Opium: A History,” Martin Booth notes that, for the Romans, the poppy was a symbol of both sleep and death. During the nineteen-eighties, Raymond and Mortimer Sackler had a great success at Purdue with an innovative painkiller called MS Contin, a morphine pill with a patented “controlled release” formula: the drug dissolved gradually into the bloodstream over several hours. (“Contin” was short for “continuous.”) MS Contin became the biggest seller in Purdue’s history. But, by the late eighties, its patent was about to expire, and Purdue executives started looking for a drug to replace it.

One executive who was centrally involved in this effort was Raymond’s son Richard, an enigmatic, slightly awkward man who, in the family tradition, had trained as a doctor. Richard had joined Purdue in 1971 as an assistant to his father, and worked his way up. His name appears on numerous medical patents. In the summer of 1990, a Purdue scientist sent a memo to Richard and several other colleagues, pointing out that MS Contin could “face such serious generic competition that other controlled-release opioids must be considered.” The memo described ongoing efforts to create a product containing oxycodone, an opioid that had been developed by German scientists in 1916.

Oxycodone, which was inexpensive to produce, was already used in other drugs, such as Percodan (in which it is blended with aspirin) and Percocet (in which it is blended with Tylenol). Purdue developed a pill of pure oxycodone, with a time-release formula similar to that of MS Contin. The company decided to produce doses as low as ten milligrams, but also jumbo pills—eighty milligrams and a hundred and sixty milligrams—whose potency far exceeded that of any prescription opioid on the market. As Barry Meier writes, in “Pain Killer,” “In terms of narcotic firepower, OxyContin was a nuclear weapon.”

Before releasing OxyContin, Purdue conducted focus groups with doctors and learned that the “biggest negative” that might prevent widespread use of the drug was ingrained concern regarding the “abuse potential” of opioids. But, fortuitously, while the company was developing OxyContin, some physicians began arguing that American medicine should reëxamine this bias. Highly regarded doctors, like Russell Portenoy, then a pain specialist at Memorial Sloan Kettering Cancer Center, in New York, spoke out about the problem of untreated chronic pain—and the wisdom of using opioids to treat it. “There is a growing literature showing that these drugs can be used for a long time, with few side effects,” Portenoy told the Times, in 1993. Describing opioids as a “gift from nature,” he said that they needed to be destigmatized. Portenoy, who received funding from Purdue, decried the reticence among clinicians to administer such narcotics for chronic pain, claiming that it was indicative of “opiophobia,” and suggesting that concerns about addiction and abuse amounted to a “medical myth.” In 1997, the American Academy of Pain Medicine and the American Pain Society published a statement regarding the use of opioids to treat chronic pain. The statement was written by a committee chaired by Dr. J. David Haddox, a paid speaker for Purdue.

Richard Sackler worked tirelessly to make OxyContin a blockbuster, telling colleagues how devoted he was to the drug’s success. The F.D.A. approved OxyContin in 1995, for use in treating moderate to severe pain. Purdue had conducted no clinical studies on how addictive or prone to abuse the drug might be. But the F.D.A., in an unusual step, approved a package insert for OxyContin which announced that the drug was safer than rival painkillers, because the patented delayed-absorption mechanism “is believed to reduce the abuse liability.” David Kessler, who ran the F.D.A. at the time, told me that he was “not involved in the approval.” The F.D.A. examiner who oversaw the process, Dr. Curtis Wright, left the agency shortly afterward. Within two years, he had taken a job at Purdue.

Mortimer, Raymond, and Richard Sackler launched OxyContin with one of the biggest pharmaceutical marketing campaigns in history, deploying many persuasive techniques pioneered by Arthur. Steven May, who joined Purdue as an OxyContin sales representative in 1999, recalled, “At the time, we felt like we were doing a righteous thing.” He used to tell himself, “There’s millions of people in pain, and we have the solution.” (May is no longer working for Purdue.) The company assembled a sales force of as many as a thousand representatives and armed them with charts showing OxyContin’s benefits. May attended a three-week training session at Purdue’s headquarters. At a celebratory dinner following the training, he was seated at a table with Richard Sackler. “I was blown away,” he recalled. “My first impression of him was ‘This is the dude that made it happen. He has a company that his family owns. I want to be him one day.’ ”

A major thrust of the sales campaign was that OxyContin should be prescribed not merely for the kind of severe short-term pain associated with surgery or cancer but also for less acute, longer-lasting pain: arthritis, back pain, sports injuries, fibromyalgia. The number of conditions that OxyContin could treat seemed almost unlimited. According to internal documents, Purdue officials discovered that many doctors wrongly assumed that oxycodone was less potent than morphine—a misconception that the company exploited.

A 1995 memo sent to the launch team emphasized that the company did “not want to niche” OxyContin just for cancer pain. A primary objective in Purdue’s 2002 budget plan was to “broaden” the use of OxyContin for pain management. As May put it, “What Purdue did really well was target physicians, like general practitioners, who were not pain specialists.” In its internal literature, Purdue similarly spoke of reaching patients who were “opioid naïve.” Because OxyContin was so powerful and potentially addictive, David Kessler told me, from a public-health standpoint “the goal should have been to sell the least dose of the drug to the smallest number of patients.” But this approach was at odds with the competitive imperatives of a pharmaceutical company, he continued. So Purdue set out to do exactly the opposite.

Sales reps, May told me, received training in “overcoming objections” from clinicians. If a doctor inquired about addiction, May had a talking point ready. “ ‘The delivery system is believed to reduce the abuse liability of the drug,’ ” he recited to me, with a rueful laugh. “Those were the specific words. I can still remember, all these years later.” He went on, “I found out pretty fast that it wasn’t true.” In 2002, a sales manager from the company, William Gergely, told a state investigator in Florida that Purdue executives “told us to say things like it is ‘virtually’ non-addicting.”

May didn’t ask doctors simply to take his word on OxyContin; he presented them with studies and literature provided by other physicians. Purdue had a speakers’ bureau, and it paid several thousand clinicians to attend medical conferences and deliver presentations about the merits of the drug. Doctors were offered all-expenses-paid trips to pain-management seminars in places like Boca Raton. Such spending was worth the investment: internal Purdue records indicate that doctors who attended these seminars in 1996 wrote OxyContin prescriptions more than twice as often as those who didn’t. The company advertised in medical journals, sponsored Web sites about chronic pain, and distributed a dizzying variety of OxyContin swag: fishing hats, plush toys, luggage tags. Purdue also produced promotional videos featuring satisfied patients—like a construction worker who talked about how OxyContin had eased his chronic back pain, allowing him to return to work. The videos, which also included testimonials from pain specialists, were sent to tens of thousands of doctors. The marketing of OxyContin relied on an empirical circularity: the company convinced doctors of the drug’s safety with literature that had been produced by doctors who were paid, or funded, by the company.

David Juurlink, who runs the division of clinical pharmacology and toxicology at the University of Toronto, told me that OxyContin’s success can be attributed partly to the fact that so many doctors wanted to believe in the therapeutic benefits of opioids. “The primary goal of medical practice is the relief of suffering, and one of the most common types that doctors see is pain,” he said. “You’ve got a patient in pain, you’ve got a doctor who genuinely wants to help, and now suddenly you have an intervention that—we are told—is safe and effective.”

Keith Humphreys, a professor of psychiatry at Stanford, who served as a drug-policy adviser to the Obama Administration, said, “That’s the real Greek tragedy of this—that so many well-meaning doctors got co-opted. The level of influence is just mind-boggling. Purdue gave money to continuing medical education, to state medical boards, to faux grassroots organizations.” According to training materials, Purdue instructed sales representatives to assure doctors—repeatedly and without evidence—that “fewer than one per cent” of patients who took OxyContin became addicted. (In 1999, a Purdue-funded study of patients who used OxyContin for headaches found that the addiction rate was thirteen per cent.)

Within five years of its introduction, OxyContin was generating a billion dollars a year. “There is no sign of it slowing down,” Richard Sackler told a team of company representatives in 2000. The sales force was heavily incentivized to push the drug. In a memo, a sales manager in Tennessee wrote, “$$$$$$$$$$$$$ It’s Bonus Time in the Neighborhood!” May, who was assigned to the Virginia area, was astonished to learn that especially skillful colleagues were earning hundreds of thousands of dollars in commissions. One year, May’s own sales were so brisk that Purdue rewarded him with a trip to Hawaii. As prescriptions multiplied, Purdue executives—and the Sackler family members on the company’s board—appeared happy to fund such blandishments. Internal budget plans described the company’s sales force as its “most valuable resource.” In 2001, Purdue Pharma paid forty million dollars in bonuses.

One day, May drove with a colleague to Lewisburg, a small city in West Virginia. They were there to visit a doctor who had been one of May’s top prescribers. When they arrived, the doctor was ashen. A relative had just died, she explained. The girl had overdosed on OxyContin.

Arthur and Mortimer Sackler each married three times, and Raymond married once. There are fifteen Sackler children in the second generation, most of whom have children of their own. The Sackler clan has pursued a variety of causes and interests. In 2011, Mortimer’s widow, Theresa, who sits on the board of Purdue, was awarded the Prince of Wales Medal for Art Philanthropy. When the medal was conferred, Ian Dejardin, the Sackler Director of the Dulwich Picture Gallery, remarked, “It’s going to be difficult not to make her sound utterly saintly.” Theresa’s daughter, Sophie, is married to the English cricket player Jamie Dalrymple, and lives in a forty-million-dollar house in London. Raymond’s thirty-seven-year-old grandson, David Sackler, runs a family investment fund, and is the only member of the third generation who sits on Purdue’s board. The fact that Purdue is privately held is a major reason that the Sacklers’ connection to OxyContin has remained obscure. A publicly traded company makes periodic disclosures to its shareholders. But Purdue, Barry Meier writes, “was the Sackler family’s private domain.”

On occasion, press accounts about OxyContin note that profits from the drug flow to the Sacklers, but these stories tend to depict the family as a monolith. As with any large clan, however, there are fissures of discord. In the eighties, Mortimer sued his ex-wife Gertraud, claiming that she had illegally taken possession of an apartment that he owned on Fifth Avenue and had loaned it out to a contingent of models and photographers. None of Arthur’s descendants sit on the company’s board. At a courthouse in Long Island, in files stemming from the family fight over Arthur’s fortune, I came across a document indicating that, after a “protracted negotiation,” Arthur’s estate “sold its one third interest in Purdue” to Raymond and Mortimer.

“I have never owned any shares in Purdue,” Michael Sackler-Berner, a Brooklyn-based singer-songwriter who is a grandson of Arthur Sackler, told me, in an e-mail. “None of the descendants of Arthur M. Sackler have ever had anything to do with, or benefited from, the sale of OxyContin.” Sackler-Berner made no mention of Librium, Valium, or MS Contin, but he added, “Given the current controversy surrounding OxyContin, I appreciate your clarifying the matter.”

Even though Mortimer Sackler had a large stake in the company, he was only an occasional presence at the Connecticut headquarters. He renounced his U.S. citizenship in 1974, reportedly for tax reasons, and lived a flamboyant life in Europe, shuttling among residences in England, the Swiss Alps, and Cap d’Antibes. (In 1999, Queen Elizabeth conferred an honorary knighthood on him, in recognition of his philanthropy.) Raymond Sackler, who lived in Connecticut, had a more modest temperament and came to his office at Purdue—where he was respectfully known as Dr. Raymond—every day. John Kallir, Arthur’s former advertising colleague, recalled, “Ray was quiet, reasonably honest, always married to the same woman. The least interesting of the three brothers.”

Almost immediately after OxyContin’s release, there were signs that people were abusing it in rural areas like Maine and Appalachia. If you ground the pills up and snorted them, or dissolved them in liquid and injected them, you could override the time-release mechanism and deliver a huge narcotic payload all at once. Perversely, users could learn about such methods by reading a warning label that came with each prescription, which said, “Taking broken, chewed or crushed OxyContin tablets could lead to the rapid release and absorption of a potentially toxic dose.” As more and more doctors prescribed OxyContin for an ever-greater range of symptoms, some patients began selling their pills on the black market, where the street price was a dollar a milligram. Doctors who were easily manipulated by their patients—or corrupted by the money in play—set up so-called pill mills, pain clinics that thrived on a wholesale business of issuing OxyContin prescriptions.

The company did not pull the drug from shelves, however, or acknowledge that it was addictive. Instead, Purdue insisted that the only problem was that recreational drug users were not taking OxyContin as directed. “Their rap has always been that a bunch of junkies ruined their product,” Keith Humphreys, the Stanford professor, said. In 2001, Michael Friedman, Purdue’s executive vice-president, testified before a congressional hearing convened to look into the alarming increase in opioid abuse. The marketing of OxyContin had been “conservative by any standard,” he maintained. “Virtually all of these reports involve people who are abusing the medication, not patients with legitimate medical needs.”

In 2002, a twenty-nine-year-old woman from New Jersey, Jill Skolek, was prescribed OxyContin for a back injury. One night, after four months on the drug, she died in her sleep, from respiratory arrest, leaving behind a six-year-old son. Her mother, Marianne Skolek Perez, was a nurse. Distraught and bewildered, she became convinced that OxyContin was dangerous. Perez wrote to F.D.A. officials, urging them to append to OxyContin packaging a warning about the risk of addiction.

The following year, Perez attended a conference on addiction at Columbia University. A sandy-haired man named Robin Hogen, wearing a pin-striped suit and a bow tie, was there, too. He was a communications specialist for Purdue, and had launched a vigorous campaign to defend the drug, warning newspapers to be careful about their coverage. “We’re going to be watching them,” he had promised. He had also enlisted Rudolph Giuliani, the former mayor of New York, and his associate Bernard Kerik to preëmpt any government crackdown. “We have to be politically Machiavellian, often, to win the day,” Hogen once said. At the Columbia event, he was asked about Perez’s daughter. He cautioned that one should not read into the tragedy any liability on Purdue’s part. The real problem, he said, was Jill Skolek: “We think she abused drugs.” (Hogen subsequently apologized for his remark. He no longer works for Purdue.)

Another speaker at the event was Purdue’s senior medical adviser, J. David Haddox, who insisted that OxyContin was not addictive. He once likened the drug to a vegetable, saying, “If I gave you a stalk of celery and you ate that, it would be healthy. But if you put it in a blender and tried to shoot it into your veins, it would not be good.” When Haddox was walking out of the event, Perez, who is petite and rail thin, deliberately bumped into him. Caught off guard, Haddox staggered backward and fell, with a clatter, into a row of folding chairs. “It was one of those Kodak moments,” Perez recalled. “It was probably the wrong thing to do. But I loved it.”

Arthur Sackler once wrote that “all health problems devolve upon the individual,” and it was Purdue’s position that OxyContin overdoses were a matter of individual responsibility, rather than the drug’s addictive properties. In addition to people like Hogen and Haddox, the company put forward several top executives to mount a defense, including Howard Udell, Purdue’s general counsel, who had been a longtime legal adviser to the Sacklers. Udell “was like Tom Hagen in ‘The Godfather,’ ” an attorney who dealt with him told me. “Very loyal to the family.” Udell was clearly aware, however, of the abuse potential of OxyContin. According to court documents, his own secretary became addicted to the drug, and was subsequently fired by Purdue.

By 2003, the Drug Enforcement Administration had found that Purdue’s “aggressive methods” had “very much exacerbated OxyContin’s widespread abuse.” Rogelio Guevara, a senior official at the D.E.A., concluded that Purdue had “deliberately minimized” the risks associated with the drug. But the company continued shifting the blame to drug abusers, creating a public-service announcement that showed a teen-ager raiding his parents’ medicine cabinet.

In a phone interview, Hogen told me that, for Purdue and the Sacklers, “there was a sense almost of betrayal—how could people put the availability of that product in jeopardy by abusing it for pleasure?” Hogen said that the company received many letters from grateful pain patients, thanking Purdue for “giving them their lives back.” Asked about his reticence to acknowledge that OxyContin might be addictive, Hogen said, “Today, addiction is broadly seen as a disease. Then, it was not. I think our understanding of addiction has grown enormously in the last fifteen years.”

People have known for thousands of years that opium derivatives are addictive, I said.

“You really need to talk to a clinician,” Hogen replied. “I’m not a doctor.”

J. David Haddox is a doctor. In 2001, he told an Associated Press reporter, “A lot of these people say, ‘Well, I was taking the medicine like my doctor told me to,’ and then they start taking more and more and more.” He added, “I don’t see where that’s my problem.” (Haddox, who still works for Purdue, declined to comment.)

The truth was that the dangers of OxyContin were intrinsic to the drug—and Purdue knew it. The time-release formula meant that, in principle, patients could safely ingest one giant dose every twelve hours. They could sleep through the night—a crucial improvement over conventional painkillers, such as morphine, which require more frequent dosing. One of Purdue’s initial advertising campaigns featured a photograph of two little dosage cups, one marked “8 a.m.” and the other “8 p.m.,” and the words “Remember, Effective Relief Just Takes Two.” But internal Purdue documents, which have emerged through litigation, show that even before the company received F.D.A. approval it was aware that not all patients who took OxyContin were achieving twelve-hour relief. A recent exposé by the Los Angeles Times revealed that the first patients to use OxyContin, in a study conducted by Purdue, were ninety women recovering from surgery in Puerto Rico. Roughly half the women required more medication before the twelve-hour mark. The study was never published. For Purdue, the business reason for obscuring such results was clear: the claim of twelve-hour relief was an invaluable marketing tool. But prescribing a pill on a twelve-hour schedule when, for many patients, it works for only eight is a recipe for withdrawal, addiction, and abuse. Notwithstanding Purdue’s claims, many people who were not drug abusers—and who took OxyContin exactly as their doctors instructed—began experiencing withdrawal symptoms between doses. In March, 2001, a Purdue employee e-mailed a supervisor, describing some internal data on withdrawal and wondering whether or not to write up the results, even though doing so would only “add to the current negative press.” The supervisor responded, “I would not write it up at this point.”

In testimonials collected by Purdue Pharma in 2001, pain patients praise OxyContin, but they also describe needing more than the recommended dose—once every twelve hours.

Doctors who prescribed OxyContin were beginning to report that patients were coming to them with symptoms of withdrawal (itching, nausea, the shakes) and asking for more medication. Haddox had an answer. In a 1989 paper, he had coined the term “pseudo-addiction.” As a pain-management pamphlet distributed by Purdue explained, pseudo-addiction “seems similar to addiction, but is due to unrelieved pain.” The pamphlet continued, “Misunderstanding of this phenomenon may lead the clinician to inappropriately stigmatize the patient with the label ‘addict.’ ” Pseudo-addiction generally stopped once the pain was relieved—“often through an increase in opioid dose.”

“When you promote these very massive doses of opioids, the more of it that is out there the more abuse there will be,” David Kessler said. “It’s almost linear.” U.S. sales of OxyContin soon exceeded those of Viagra. Everywhere the drug spread, addiction followed. To Steven May, the sales representative in Virginia, it seemed as if the problems associated with OxyContin were metastasizing, “like a cancer.”

According to Robin Hogen, the members of the Sackler family “were unified in their shock that this was happening to a product they were very proud of.” The Sacklers did not have an arm’s-length relationship with Purdue, Hogen said: “This was an active family and an active board.” In 1999, Richard Sackler became Purdue’s president. As the head of a privately held company, however, he felt no pressure to be the public face of the business, and he never appeared at forums where people like Haddox defended Purdue. Indeed, though Sackler presided over the tremendously successful launch of OxyContin, he has never given an on-the-record interview about the drug. “I’ve had a lot of experience with Purdue over the years, in different settings, but I’ve never even seen Richard Sackler,” the addiction specialist Andrew Kolodny, who is a frequent Purdue critic, told me. “I don’t think I’d know him if he was standing in front of me.”

Even after it became clear that OxyContin was being widely abused, Purdue refused to concede that it posed risks. Company leaders worried mainly that attempts to stem overdoses might deprive pain patients of access to the drug. “They said, ‘We need to make sure that these products are available for patients,’ ” Hogen said. “That was their sole focus.” According to Steven May, the sales force was instructed to ride out the controversy, ignore abuse reports, and “sell through it.” As late as 2003, the F.D.A. sent Purdue a warning letter about ads that “grossly overstate the safety profile of OxyContin by not referring in the body of the advertisements to serious, potentially fatal risks.”

In his congressional testimony, Michael Friedman, Richard Sackler’s deputy, said that Purdue first became aware of problems with OxyContin only in April, 2000, after a series of press reports about people abusing it recreationally in Maine. But Purdue didn’t need the media’s help to know that something was seriously off with the distribution of OxyContin. For years, it had maintained a contract with I.M.S., a little-known company, co-founded by Arthur Sackler, that furnished its clients with fine-grained information about the prescribing habits of individual doctors. Purdue’s sales representatives used the data to figure out which doctors to target.

Such data could also be used to track patterns of abuse. “They know exactly what people are prescribing,” Kolodny said. “They know when a doctor is running a pill mill.” At the 2001 hearing, James Greenwood, a Pennsylvania congressman, asked Friedman whether Purdue would take any action if, say, I.M.S. data revealed that a rural osteopath was writing thousands of prescriptions.

Friedman replied that it was not up to Purdue to assess “how well a physician practices medicine.”

“Why do you want that information, then?” Greenwood pressed, before answering his own question: “To see how successful your marketing techniques are.”

Greenwood then observed that, in a recent case involving a Pennsylvania doctor, Richard Paolino, who was wantonly overprescribing OxyContin, a local pharmacist had alerted the authorities. “He looked at this data and he said, ‘Holy God, there is some guy in Bensalem called Paolino, and he’s writing prescriptions out the wazoo,’ ” Greenwood said. “Now, he had that data and he blew the whistle. And you had that data. What did you do?”

Purdue had not alerted the authorities. Clinicians like Paolino were breaking the law—he was sentenced to a minimum of thirty years in prison. But overprescribing generated tremendous revenue for the company. According to four people I spoke with, at Purdue such prescribers were given a name that Las Vegas casinos reserve for their most prized gamblers: whales.

In July, 2001, Richard Blumenthal, who was then the attorney general of Connecticut, wrote to Richard Sackler. “I have been increasingly dismayed and alarmed about the problems and escalating abuse of OxyContin,” he began, citing overdose deaths, addiction, pharmacy robberies, and “the astonishing growth in state funding” that was being used to pay for OxyContin prescriptions through Medicaid and Medicare. Blumenthal acknowledged that other prescription drugs were also abused. “But OxyContin is different,” he wrote. “It is more powerful, more addictive, more widely sold, more illicitly available, and more publicized.” He urged Purdue to “overhaul and reform” its marketing of OxyContin.

The Sacklers disregarded his recommendation, and so in 2004 Blumenthal filed a complaint against Purdue, on behalf of the State of Connecticut. It cited data indicating that a fifth of OxyContin prescriptions were now for dosing intervals shorter than twelve hours. In fact, Blumenthal obtained Purdue records indicating that company officials knew by 1998 that prescriptions for eight-hour intervals were becoming more and more frequent. In one document, a Purdue employee called the numbers “very scary.”

Such alarm over off-label dosing may have been prompted less by concern about public health than by considerations of profit. If OxyContin was being widely prescribed at intervals of fewer than twelve hours, the company might lose its “two pills a day” marketplace advantage against cheaper alternatives, like generic morphine, and insurers could start refusing to cover the costs. As early as 1997, some benefit plans had begun citing abuse of OxyContin as an excuse not to pay. In a 1997 e-mail, Richard Sackler urged colleagues to counter this resistance, warning that, for insurance companies, “‘addiction’ may be a convenient way to just say ‘NO.’”

Purdue has been sued thousands of times over OxyContin since its release. (Steven May, the sales rep, initiated a whistle-blower suit years after leaving the company; it was dismissed, on procedural grounds.) In 2002, Howard Udell said that the firm would defend itself “to the hilt.” The next year, a New York trial lawyer named Paul Hanly assembled a lawsuit, signing up five thousand patients who said that they’d become addicted to OxyContin after receiving a doctor’s prescription. In discovery, Hanly obtained thousands of documents. “They demonstrated that this company had set out to perpetrate a fraud on the entire medical community,” he told me. “These pronouncements about how safe the drug was emanated from the marketing department, not the scientific department. It was pretty shocking. They just made this stuff up.”

In 2006, Purdue settled with Hanly’s clients, for seventy-five million dollars. Shortly afterward, the company pleaded guilty, in a case brought by federal prosecutors in Virginia, to criminal charges of misbranding, and acknowledged that Purdue had marketed OxyContin “with the intent to defraud or mislead.” (Rudolph Giuliani had tried, on Purdue’s behalf, to get the lead prosecutor to scuttle the case.) Michael Friedman, the executive vice-president, pleaded guilty to a criminal misdemeanor, as did Howard Udell and the company’s chief medical officer, Paul Goldenheim.

Marianne Perez attended the sentencing, in Virginia. “I was on cloud nine,” she recalled. She had been working with the prosecution, and doing everything she could to inform the public about the dangers of OxyContin. Before the sentence was handed down, Perez delivered a victim-impact statement. “I want to know why the Sackler brothers have not been held accountable,” she said. (Richard Sackler, despite his leadership role at Purdue, had not been charged.)

During a break in the proceedings, Perez looked over at Friedman, Goldenheim, and Udell, and told herself, “I could reach over, at ninety-eight pounds, and smack one of them.” This time, she restrained herself. Instead, she told them, “You are sheer evil. You are bastards.” The executives reddened, but said nothing. They all received probation, and were ordered, collectively, to pay nearly thirty-five million dollars in fines. Purdue agreed to pay an additional six hundred million. Given the billions of dollars that the Sacklers and Purdue had reaped from OxyContin, some observers felt that the company had got off easy. Arlen Specter, the Republican senator from Pennsylvania, remarked that such fines amounted to “expensive licenses for criminal misconduct.”

Arthur Sackler wrote a regular column for the Medical Tribune, and one of his fixations was the unethical behavior of tobacco companies. In 1979, he critiqued the “weasel-worded warning” on cigarette packages as insufficient, arguing that the “hazard to health should be more specific.” He also condemned newspapers and magazines for accepting “misleading” advertising about cigarettes, and contended that the publishers must “square with their own consciences their contribution to our national mortality.”

In 1998, the tobacco industry, which had been sued by dozens of states, entered into the largest civil-litigation settlement in history, agreeing to pay two hundred and forty-six billion dollars. Tobacco and opioids are different in significant ways. The F.D.A. approved OxyContin as a medicine, and, whereas tobacco can kill you even when used as directed, Purdue would argue that this isn’t the case with OxyContin. Mike Moore, who, as Mississippi’s attorney general, played a key role in the tobacco litigation, noted another difference: the tobacco companies had more money to spare than Purdue does. “To resolve the opioid problem, you’re going to need billions,” he said. “Treatment alone could be fifty billion dollars or more. And you need prevention and education programs on top of that.”

Moore is now working with Paul Hanly and other attorneys to bring a fresh wave of lawsuits against Purdue and other pharmaceutical companies. Ten states have filed suits, and private attorneys are working in partnership with dozens of cities and counties to bring others. Many public officials are furious at the makers of powerful painkillers. Prescriptions are expensive, and taxpayers often foot the bill, through programs like Medicaid. Then, as the ruinous consequences of opioid addiction take hold, the public must pay again—this time for emergency services, addiction treatment, and the like. Moore feels that the Sackler family, as the initial author and a prime beneficiary of the epidemic, should be publicly shamed. “I don’t call it Purdue. I call it the Sackler Company,” he said. “They are the main culprit. They duped the F.D.A., saying it lasted twelve hours. They lied about the addictive properties. And they did all this to grow the opioid market, to make it O.K. to jump in the water. Then some of these other companies, they saw that the water was warm, and they said, ‘O.K., we can jump in, too.’ ” There may be significant legal distinctions between a tobacco company and an opioid producer, but to Moore the ethical parallel is unmistakable: “They’re both profiting by killing people.”

One day in August, 2015, a plane landed in Louisville, Kentucky, and Richard Sackler stepped out, surrounded by attorneys. Eight years earlier, the State of Kentucky had sued Purdue, charging the company with deceptive marketing. Greg Stumbo, the state attorney general at the time, initiated the suit; the son of a cousin of his had fatally overdosed on OxyContin. Purdue fought the suit with its customary rigor, pushing to move the proceedings elsewhere, on the ground that the company could not get a fair trial in Pike County, Kentucky—the rural stretch of coal country where the state intended to try the case. In support of this motion, the company commissioned a demographic study of Pike County and submitted it to the court, as an illustration of potential bias in the jury pool. The report was revealing in ways that Purdue may not have intended: according to the filing, twenty-nine per cent of the county’s residents said that they or their family members knew someone who had died from using OxyContin. Seven out of ten respondents described OxyContin’s effect on their community as “devastating.”

A judge ruled that Purdue could not shift the venue for the trial, and so Richard Sackler flew to Louisville. He gave a deposition at a law firm. Four lawyers questioned him about his role in the development and the marketing of OxyContin. Tyler Thompson, the lead attorney, told me that Sackler’s demeanor during the session reminded him of Jeremy Irons’s portrayal of Claus von Bülow, the aristocrat accused of murdering his wife, in the 1990 bio-pic “Reversal of Fortune.” “A smirk and a so-what attitude—an absolute lack of remorse,” Thompson said. “It reminded me of these mining companies that come in here and do mountaintop removal, and leave a mess and just move on: ‘It’s not my back yard, so I don’t care.’ ” Mitchel Denham, a former litigator in the Kentucky attorney general’s office, also attended the deposition. “It was surreal,” he recalled. “We were face to face with the guy whose company had helped to create the opioid epidemic.” Denham told me that, in preparing for trial, he discovered a photograph of the 1997 Pikeville High School football team. “Nearly half the players had died of overdoses, or were addicted,” he said. “It was going to be a pretty good visual.”

But Denham never presented the photograph to a jury, because before the case could go to trial Purdue settled, for twenty-four million dollars. This was a coup for the Sacklers. The settlement was more than Purdue’s original offer—half a million dollars—but still totally incommensurate with Pike County’s needs; Purdue admitted no liability; and, in settling, the company sealed from public view both Richard Sackler’s deposition and internal documents obtained through discovery. Purdue has sometimes claimed to have never “lost a case” related to OxyContin, but it’s more accurate to say that the company has never allowed a case to go to trial, often settling rather than litigating the culpability of the company—and the Sacklers—in open court. “That’s the main reason these folks don’t go to trial,” Denham said. “Because all these documents could end up in the public record.” The Kentucky prosecutors were required to destroy millions of documents, or return them to Purdue. The medical-news Web site STAT subsequently sued to unseal Richard Sackler’s deposition. A state judge ruled in its favor, but Purdue appealed. I spent several months trying to obtain a copy of the deposition, but, because it remains under a protective order while Purdue appeals the matter, no lawyer would share it with me. Mike Moore said, “The idea that they’re fighting so hard to keep this deposition hidden should tell you something.”

Richard Sackler stepped down as Purdue’s president in 2003, but stayed on as co-chairman of the company’s board. After spending several years as an adjunct professor of genetics at Rockefeller University, he moved to Austin, Texas, in 2013. He lives in a modern hilltop mansion on the outskirts of the city, in an area favored by tech entrepreneurs. According to tax disclosures from his personal foundation, he has continued giving money to Yale, but his largest donation in 2015 was a hundred-thousand-dollar gift to a neoconservative think tank, the Foundation for Defense of Democracies. Through a representative, Sackler declined to speak with me. I contacted a dozen other members of the Sackler family, but none of them would answer questions about OxyContin. Jo Sheldon, a London-based media adviser, called me, and said that she works with some of the Sacklers. (She would not identify which ones.) When I told her that I had questions for the Sacklers, she said that my inquiries would be better directed to Purdue. She said of the Sacklers, “Some of them are still quite involved in Purdue, but some have absolutely nothing to do with it,” apart from depositing checks.

Given the sometimes fractious nature of the Sackler family, it was striking that they were united in their silence on the subject of OxyContin. These were urbane, expensively educated, presumably well-informed people. Could they conceivably be unaware of the accumulated evidence about the tainted origins of their fortune? Did they simply put it out of mind? “Greed can get people to rationalize pretty bad behavior,” Andrew Kolodny had told me. Someone who knows Mortimer, Jr., socially told me, “I think for him, most of the time, he’s just saying, ‘Wow, we’re really rich. It’s fucking cool. I don’t really want to think that much about the other side of things.’ ”

Paul Hanly, the lawyer, said that the Sacklers’ steadfast refusal to address the legacy of OxyContin may just be a legal tactic—and a shrewd one. “The more interviews you give, the more targets you create for lawyers like me, and for government investigators,” he said. I wondered whether philanthropy might represent, for at least some of the Sacklers, a form of atonement. But, when you consider the breadth of the family’s donations, one field is conspicuously lacking: addiction treatment, or any other measures that might serve to counter the opioid epidemic.

In August, 2010, Purdue quietly replaced OxyContin with a drug that was subtly different. The company had been granted patents for a reformulated version of OxyContin. If you crushed these new pills, they became not a fine, dissolvable powder but an unwieldy gummy substance. Purdue had received F.D.A. approval for the reformulation, in part, by touting the ostensible safety of the new product. The F.D.A. had approved a label, the first of its kind, that included a claim about the drug’s “abuse deterrent” properties.

In an interview, Craig Landau, Purdue’s C.E.O., told me, “A very large proportion of Purdue’s R. & D. efforts post-2001 was dedicated toward addressing the specific vulnerability of the original OxyContin product.” To a casual observer, it might have seemed that the makers of OxyContin, after years of obstructing efforts to curb the disastrous impacts of their painkiller, had finally seen the error of their ways. But Purdue was almost certainly motivated by another consideration: it needed to block competition from generic drugs. Arthur Sackler had often used the pages of the Medical Tribune to criticize generics. In 1985, the paper had published a story, “Schizophrenics ‘Wild’ on Weak Generic,” describing how “all hell broke loose” at a veterans’ hospital after the psychiatric unit switched from a brand-name antipsychotic to a generic. (According to the Times, the F.D.A. investigated and found that the story was bogus, because “the generic had been introduced six months before the purported problems began.”) I spoke with a leading patent lawyer who frequently represents manufacturers of generic drugs, and she said that companies often make a minor tweak to a branded product shortly before the patent expires, in order to obtain a new patent and reset the clock on their exclusive right to produce the drug. The patent for the original OxyContin was set to expire in 2013.

Purdue had long denied that the original OxyContin was especially prone to abuse. But, upon receiving its patents for the reformulated drug, the company filed papers with the F.D.A., asking the agency to refuse to accept generic versions of the original formulation—because they were unsafe. The F.D.A., ever obliging, agreed, blocking any low-cost generic competition for Purdue. For more than a year, Purdue continued to sell the original formulation of OxyContin in Canada. According to a recent study, OxyContin sales in Windsor, Ontario—just across the border from Detroit—suddenly quadrupled, a clear indication that the pills were being purchased for the U.S. black market. Through I.M.S. tracking data, Purdue would have been able to monitor the Canadian surge, and to deduce the reason for it. (The company acknowledges that it was aware of the spike in sales, and maintains that it alerted authorities, but will not say when it did so.)

By the time Purdue reformulated OxyContin, the country was in the middle of a full-blown epidemic. Andrew Kolodny, the addiction specialist, told me that many older people remain addicted to the reformulated OxyContin, and continue to obtain the drug through prescriptions. These people purchase the drug legally, and swallow the pills whole, as instructed. “That’s Purdue’s market now,” Kolodny said. Younger people, who can less readily secure prescriptions for pain—and for whom OxyContin may be too expensive—have increasingly turned to black-market substitutes, including heroin. As Sam Quinones details in his 2015 book, “Dreamland: The True Tale of America’s Opiate Epidemic,” heroin dealers from Mexico fanned out across the U.S. to supply a burgeoning market of people who had been primed by pill addiction. This is one dreadful paradox of the history of OxyContin: the original formulation created a generation addicted to pills; the reformulation, by forcing younger users off the drug, helped create a generation addicted to heroin. A recent paper by a team of economists, citing a dramatic uptick in heroin overdoses since 2010, is titled “How the Reformulation of OxyContin Ignited the Heroin Epidemic.” A survey of two hundred and forty-four people who entered treatment for OxyContin abuse after the reformulation found that a third had switched to other drugs. Seventy per cent of that group had turned to heroin.

Perhaps the most surprising aspect of Quinones’s investigation is the similarities he finds between the tactics of the unassuming, business-minded Mexican heroin peddlers, the so-called Xalisco boys, and the slick corporate sales force of Purdue. When the Xalisco boys arrived in a new town, they identified their market by seeking out the local methadone clinic. Purdue, using I.M.S. data, similarly targeted populations that were susceptible to its product. Mitchel Denham, the Kentucky lawyer, told me that Purdue pinpointed “communities where there is a lot of poverty and a lack of education and opportunity,” adding, “They were looking at numbers that showed these people have work-related injuries, they go to the doctor more often, they get treatment for pain.” The Xalisco boys offered potential customers free samples of their product. So did Purdue. When it first introduced OxyContin, the company created a program that encouraged doctors to issue coupons for a free initial prescription. By the time Purdue discontinued the program, four years later, thirty-four thousand coupons had been redeemed.

Purdue Pharma now acknowledges that there is an opioid crisis, but maintains that it has taken every available step to address it, from sponsoring “prescription monitoring” programs in some states to underwriting drug-abuse education. Craig Landau, the C.E.O., told me, “If the Holy Grail is a pain medicine that is safe and effective for patients with severe pain but carries no abuse risk, we haven’t found it yet.” He added that the company has been trying to develop “non-opioid pain products.” Purdue likes to emphasize that there are many other powerful painkillers, and that OxyContin never had more than two per cent of the market for opioids. This is true in terms of the number of prescriptions. But most painkillers are prescribed for very short periods—following surgery, for instance—and in relatively small doses, whereas OxyContin’s sales have been driven by long-term, high-dose prescriptions. If one measured market share by the actual volume of narcotics administered, OxyContin’s would be considerably higher. Some doctors I spoke with estimated that it could be as high as thirty per cent.

The United States accounts for roughly a third of the global market for opioid painkillers. But, as politicians and journalists have raised alarms over the addiction crisis, many American doctors have grown leery, again, of prescribing these drugs. In a statement, Purdue acknowledged that even patients “who take OxyContin in accordance with its F.D.A.-approved labeling instructions will likely develop physical dependence.” The company maintains that physical dependence is different from addiction, but Jane Ballantyne, the president of Physicians for Responsible Opioid Prescribing, said that, for patients, this can be a meaningless distinction: if they find themselves unable to stop taking a drug, for fear of crippling withdrawal, “at a certain point that might as well be addiction.” The drugstore chain CVS, which has been accused of profiteering from opioids, recently announced that it plans to limit prescriptions for powerful doses to one week’s worth, a change that could have a major impact on the abuse of these drugs. It may also be that OxyContin has achieved market saturation. In recent years, American clinicians have issued about a quarter of a billion opioid prescriptions annually. Last year, in Ohio, a state particularly hard hit by the epidemic, 2.3 million residents—roughly one in five people in the state—received a prescription for opioids. In 2012, the Milwaukee Journal Sentinel published a story about pain patients who had offered testimonials about the wonders of OxyContin in Purdue promotional videos. Johnny Sullivan, the construction worker who had talked about OxyContin easing his back pain, became addicted to the drug. In 2008, while driving home from a hunting trip, he apparently blacked out; he flipped his truck, and died instantly. In a Purdue brochure, Sullivan is quoted as saying that OxyContin pills “don’t put me in a stupor or make me groggy.”

David Juurlink, the Toronto doctor, told me that opioids are problematic even for users who don’t succumb to addiction. “Opioids really do afford pain relief—initially,” he said. “But that relief tends to diminish over time. That’s, in part, why people increase the dose. They are chasing pain relief from a drug that has failed. I see all these people who are convinced they are one of the ‘legitimate’ pain patients. They’re on a massive dose of opioids, and they’re telling me they need this medication, which is clearly doing them harm. For many of them, the primary benefit of therapy, at this point, is not going into withdrawal.”

Even Russell Portenoy, the Purdue-funded doctor who advocated for wider long-term use of opioids, has reassessed his views. “Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation?” he said to the Wall Street Journal in 2012. “I guess I did.” (In a statement, Portenoy told me that he has “refocussed” his approach to pain management, adding, “No funder has had any undue influence over my thinking.”)

In his defense, Portenoy has pointed out that, two decades ago, doctors did not know what they know now about opioids and addiction. The Sackler family and Purdue Pharma could have taken responsibility in a similar spirit: apologizing for their role in unleashing a national catastrophe while noting that, during the nineties, they had relied on a series of mistaken assumptions about the safety of OxyContin. But Purdue has continued to fight aggressively against any measures that might limit the distribution of OxyContin, in a way that calls to mind the gun lobby’s resistance to firearm regulations. Confronted with the prospect of modest, commonsense measures that might in any way impinge on the prescribing of painkillers, Purdue and its various allies have responded with alarm, suggesting that such steps will deny law-abiding pain patients access to medicine they desperately need. Mark Sullivan, a psychiatrist at the University of Washington, distilled the argument of Purdue: “Our product isn’t dangerous—it’s people who are dangerous.”

Last year, the C.D.C., which formally declared an opioid epidemic in 2011, introduced the first set of guidelines to help reduce the prescribing of strong painkillers like OxyContin. “Opioids should not be considered first-line or routine therapy for chronic pain,” the guidelines said, recommending that doctors first consider “non-pharmacologic” approaches, such as physical therapy, and “non-opioid pharmacologic” treatments.

Purdue and other pharmaceutical companies have long funded ostensibly neutral nonprofit groups that advocate for pain patients. The C.D.C. guidelines were nonbinding, yet many of these organizations fought to prevent the agency from releasing them. This kind of obstruction is typical at both the state and the federal level. A recent series by the Associated Press and the Center for Public Integrity revealed that, after Purdue made its guilty plea, in 2007, it assembled an army of lobbyists to fight any legislative actions that might encroach on its business. Between 2006 and 2015, Purdue and other painkiller producers, along with their associated nonprofits, spent nearly nine hundred million dollars on lobbying and political contributions—eight times what the gun lobby spent during that period.

Since Purdue made it more difficult to grind OxyContin pills, prescriptions have reportedly plummeted by forty per cent. This suggests that nearly half of the original drug’s consumers may have been crushing it to get high. As David Juurlink pointed out to me, it is a misnomer to call the reformulation an “abuse deterrent.” It can still be abused—and is, widely, by people who become addicted by swallowing the pills, just as the bottle instructs. But Purdue, facing a shrinking market and rising opprobrium, has not given up the search for new users. In August, 2015, over objections from critics, the company received F.D.A. approval to market OxyContin to children as young as eleven.

Forbes estimates that the Sacklers continue to receive some seven hundred million dollars a year from the family companies, and, as the Sacklers are surely aware, the real future of OxyContin may be global. Many big companies, once their sales plateau in America, look abroad. After introducing OxyContin in the U.S., Purdue moved into Canada and England. At the University of Toronto, the company sponsored a class on pain management for medical and dental students. The instructor was a member of Purdue’s speakers’ bureau. Students received a complimentary textbook, produced by Purdue, that described oxycodone as a “moderate” opioid. The course was discontinued after students and doctors criticized it; one of the critics was Rick Glazier, a physician at the university, whose son, Daniel, had fatally overdosed on OxyContin in 2009.

As OxyContin spread outside the U.S., the pattern of dysfunction repeated itself: to map the geographic distribution of the drug was also to map a rash of addiction, abuse, and death. But the Sackler family has only increased its efforts abroad, and is now pushing the drug, through a Purdue-related company called Mundipharma, into Asia, Latin America, and the Middle East. Part of Purdue’s strategy from the beginning has been to create a market for OxyContin—to instill a perceived need by making bold claims about the existence of large numbers of people suffering from untreated chronic pain. As Purdue moves into countries like China and Brazil, where opioids may still retain the kind of stigma that the company so assiduously broke down in the United States, its marketing approach has not changed. According to a Los Angeles Times report from 2016—well after the Sacklers’ playbook for OxyContin had been repudiated by the medical establishment as possibly the main driver of the opioid epidemic—Mundipharma commissioned studies showing that millions of people in these countries suffered from chronic pain. The company has organized junkets, and paid doctors to give presentations extolling OxyContin’s virtues. In fact, certain doctors who are currently flogging OxyContin abroad—“pain ambassadors,” they are called—used to be on Purdue’s payroll as advocates for the drug in the U.S.

The Times report described Joseph Pergolizzi, Jr.—a Florida doctor who runs a pain-management clinic and hawks a pain-relieving cream of his own invention on cable TV—giving paid talks in places like Brazil about the merits of OxyContin. In Mexico, Mundipharma has asserted that twenty-eight million people—a quarter of the population—suffer from chronic pain. In China, the company has distributed cartoon videos about using opioids for pain relief; other promotional literature cites the erroneous claim that rates of addiction are negligible. In a 2014 interview, Raman Singh, a Mundipharma executive, said, “Every single patient that is in emerging markets should have access to our medicines.” The term “opiophobia” has largely fallen into disuse in America, for obvious reasons. Mundipharma executives still use it abroad.

“It’s a parallel to what the tobacco industry did,” Mike Moore told me. “They got caught in America, they saw their market share decline, so they export it to places with even fewer regulations than we have.” He added, “You know what’s going to happen. You’re going to see lots and lots of death.” In May, several members of Congress wrote to the World Health Organization, urging it to help stop the spread of OxyContin, and mentioning the Sackler family by name. “The international health community has a rare opportunity to see the future,” they wrote. “Do not allow Purdue to walk away from the tragedy they have inflicted on countless American families simply to find new markets and new victims elsewhere.” David Kessler, the former F.D.A. commissioner, believes that the destigmatization of opioids in the U.S. represents one of the “great mistakes” of modern medicine. When I asked for his thoughts on Mundipharma’s efforts to market OxyContin abroad, he said, “It gives me a sick feeling. It makes me ill.”

Earlier this year, Peter Salovey, the president of Yale, announced that the university will rename a residential college that was named for John C. Calhoun, because Calhoun’s “legacy as a white supremacist and a national leader who passionately promoted slavery as a ‘positive good’ fundamentally conflicts with Yale’s mission and values.” This move, which was not without its critics, was emblematic of a broader trend to look back skeptically at individuals who were venerated in earlier epochs, and ask how they should be judged by the moral standards of today. At Oxford, a Rhodes Scholar from South Africa recently led a campaign to take down a statue of Cecil Rhodes.

One great fortune—and reputation—that has evaded such scrutiny is that of the Sacklers, a family whose dubious business practices are not an artifact of previous centuries but an ongoing reality. If present statistics are any indication, in the time it likely took you to read this article six Americans have fatally overdosed on opioids. Yet Yale appears to be in no hurry to rename its Raymond and Beverly Sackler Institute for Biological, Physical and Engineering Sciences, or its Richard Sackler and Jonathan Sackler Professorship of Internal Medicine. Perhaps it’s because the Sacklers, unlike the Calhoun family, still have a fortune to give away.

“It’s amazing how they are left out of the debate about causation, but also about solutions,” Allen Frances, the Duke psychiatrist, said of the Sacklers. “A truly philanthropic family, looking at the last twenty years, would say, ‘You know, there’s several million Americans who are addicted, directly or indirectly, because of us.’ Real philanthropy would be to contribute money to taking care of them. At this point, adding their name to a building—it rings hollow. It’s not philanthropy. It’s just a glorification of the Sackler family.” According to the American Society of Addiction Medicine, more than two and a half million Americans have an opioid-use disorder. Frances continued, “If the Sacklers wanted to clear their name, they could take a very substantial fraction of that fortune and create a mechanism for providing free treatment for everyone who’s become addicted.” Alfred Nobel, the inventor of dynamite, created the Nobel Peace Prize. In recent years, several philanthropic organizations run by the descendants of John D. Rockefeller have devoted resources to addressing climate change and critiquing the environmental record of the oil company he founded, now called ExxonMobil. Last year, Valerie Rockefeller Wayne told CBS, “Because the source of the family wealth is fossil fuels, we feel an enormous moral responsibility.”

Mike Moore, the former Mississippi attorney general, believes that the Sacklers will feel no pressure to emulate this gesture until more of the public becomes aware that their fortune is derived from the opioid crisis. Moore recalled his initial settlement conference with tobacco-company C.E.O.s: “We asked them, ‘What do you want?’ And they said, ‘We want to be able to go to cocktail parties and not have people come up and ask us why we’re killing people.’ That’s an exact quote.” Moore is puzzled that museums and universities are able to continue accepting money from the Sacklers without questions or controversy. He wondered, “What would happen if some of these foundations, medical schools, and hospitals started to say, ‘How many babies have become addicted to opioids?’ ” An addicted baby is now born every half hour. In places like Huntington, West Virginia, ten per cent of newborns are dependent on opioids. A district attorney in eastern Tennessee recently filed a lawsuit against Purdue, and other companies, on behalf of “Baby Doe”—an infant addict.

Purdue executives won’t be able to settle every case against them, Moore believes. “There’s going to be a jury somewhere, someplace, that’s going to hit them with the largest judgment in the nation’s history,” he said. Paul Hanly noted that, in the face of a crippling judgment, Purdue may have to declare bankruptcy. “But I’m certainly not going to walk away if they do,” he said. “At that point, I would start looking closely at individual liability on the part of the Sacklers.”

Robin Hogen, the former Purdue communications executive, said, “I don’t want to be portrayed as an apologist for what is clearly a public-health crisis. But I wanted to make sure you spoke to someone who had very high regard for the Sackler family. The Sacklers were first class in everything they did.” I asked him what he would say to the doctors and the public-health officials who believe that the heirs of Raymond and Mortimer Sackler bear some moral responsibility for the epidemic. “I’m not a doctor,” Hogen demurred. “I really can’t comment.”

The Sacklers have always excelled at the confidence game of marketing, and it struck me that the greatest trick they ever pulled was to write the family out of the history of the family business. I was reminded of Arthur Sackler’s admonition that you should endeavor to leave the world a better place than it was when you came into it, and I wondered about the moral arithmetic of the Sacklers’ deeds. But the family, through a Purdue representative, declined to comment.

I recently went to Amagansett, on Long Island, to meet a man I’ll call Jeff. At a restaurant, he told me about his struggles with addiction. A decade ago, when he was a teen-ager, he started abusing opioids. They were “everywhere,” he recalled. He particularly liked OxyContin, for the “clean high” it provided. After sucking the pill’s red coating off, he crushed the rest with the edge of a cigarette lighter, then snorted it. He didn’t inject it. “When I was growing up, I always told myself, ‘I’ll never stick a needle in my arm,’ ” he said.

In a soft, unflinching tone, Jeff recounted the next decade of his life: he kept abusing painkillers, met a woman, fell in love, and introduced her to opioids. One day, his dealer was out of pills and said, “I’ll sell you a bag of heroin for twenty bucks.” Jeff was reluctant, but when withdrawal set in he acquiesced. At first, he and his girlfriend snorted heroin. “But you build up a tolerance, just like with the pills,” he said, and eventually they started injecting it. They were high when they got married. Jeff’s wife gave birth to a boy, who was addicted to opioids. “The doctors weaned him off with droplets of morphine,” he said.

After a long stretch in rehab, Jeff has been sober for more than a year. His baby is healthy, and his wife is clean, too. Looking back, he said, he feels that an impulsive youthful decision to snort pills set him on a path from which he could not deviate. “It was all about the drug,” he said. “I just created a hurricane of destruction.”

We left the restaurant and strolled along a leafy side street flanked by grand houses. During the worst years of his addiction, Jeff worked as a tradesman in the area. I had asked him to show me a property that he had serviced, and we stopped outside a sprawling estate that was mostly hidden behind dense shrubbery. It was the home of Mortimer Sackler, Jr. Jeff, who knew about the family, appreciated the irony. “I couldn’t tell you how many times I was on that property, sitting in a work truck, snorting a pill,” he said.

We reached an ornamental wooden gate, beyond which was a yard dominated by a stately weeping willow. As I was admiring the tree, Jeff said that, for the people who maintained the grounds, it was “a pain in the ass.” Whenever the wind picks up, he explained, branches break and scatter all over the lawn. “But the place has to be flawless,” he said. “There can’t be a leaf on the ground.” So a crew comes by regularly, to clear away the mess.

Written by Patrick Radden Keefe and published by The New Yorker ~ October 30 2017.

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