John Bonica (1917–1994) was not the first person to think that anesthetic techniques and drugs could be used to help people with chronic pain. But he was a larger-than-life character with a larger-than-life vision, and because of where his vision led us, he is considered to be the founding father of pain medicine. His belief, shared by many pioneers of the field of pain medicine, was that the combined forces of researchers and clinicians from a wide range of disciplines could make significant headway in reducing people’s pain. The immediate effect was a growth in multidisciplinary pain clinics, a recognition of the value of psychologists in the management of chronic pain, an international consolidation of pain research, and the inception of pain-focused professional groups and societies. Yet, chronic pain and its treatment are larger problems today than they were in Bonica’s time, and an opioid crisis in the United States has been blamed in part on the overreach of pain specialists. Bonica worked with the World Health Organization to encourage global availability of opioids for the treatment of cancer pain, which in his time tended to be a rapidly fatal disease that caused a huge amount of suffering at the end of life. But he and other pioneers never considered opioids to be suitable treatment for chronic pain. In fact, in Bonica’s own multidisciplinary pain program at the University of Washington in Seattle, patients were weaned from opioids in recognition that it was difficult to make headway with chronic pain if people were taking opioids. What changed all that was greed.

In his book Empire of Pain, Patrick Radden Keefe exposes the incredible greed and hubris of a single family—the Sacklers. Their name is known all over the world because of their philanthropic support of the arts. There were Sackler galleries in London, Paris, New York, Washington, D.C., and Boston, but many institutions now are rejecting the name. But the Sackler family was always careful to shield itself from public recognition of the source of its billions—Purdue Pharma and its drug OxyContin. Unlike many other philanthropists who delight in having the name of their company preserved in perpetuity on the portals of buildings, the Sacklers shielded themselves from the name Purdue Pharma. It was as if, despite their protestations, they knew that there was something shameful about their business. And there was. Turning to what has become a huge resource of exposed secret documents from the multitude of lawsuits against Purdue Pharma, Keefe has woven new evidence of Sackler deceit into a rip-roaring and highly readable tale of how one family managed to turn the heads of a whole medical community. It all started with the older brother, Arthur, who became a pioneer of pharmaceutical advertising. Arthur saw medical advertising as a seduction of both physicians and patients, and so successful were his methods that they were at once considered a triumph for the industry and a scourge for society. OxyContin was not launched until after Arthur’s death, but he had taught his two younger brothers, Mortimer and Raymond, the art of persuasion. It was their methods, probably above all else, that made OxyContin such a successful drug. They pervaded doctors’ offices, regulatory bodies, the U.S. Food and Drug Administration, pain professional societies, The Joint Commission (health facility quality assurance in the United States), postgraduate education, national and international pain meetings, and patient groups. They broke down the restraint in opioid prescribing that had existed for decades because of previous opioid epidemics. The Sacklers presented themselves as owners in name only, but it turns out that their involvement was distinctly hands-on. They and the company’s executives were given early evidence that their drug was leaking into the community and causing problems, information they concealed and failed to act upon, while continuing to insist that it was bad people who were the problem, and not their drug, which would “rarely cause addiction if used to treat pain.” Years went by, and the societal problem caused by their drug grew into a problem that is now very difficult to reverse. To make matters worse, other companies were so taken with the success of OxyContin, that they followed suit with their own opioid products and promoted them using Purdue Pharma’s playbook.

The Sacklers were not the only people who profited from pain. People are willing to pay a great deal of money for the hope of pain relief. Countless profitable ventures have grown out of Bonica’s idea that medicine had the means to reduce pain, many of which deceive in their own right. But none has done as much harm to the ideals of Bonica and the early pioneers of pain medicine as the opioid debacle. The pioneers’ efforts were not about profiting from pain. They did not promote opioid treatment of chronic pain. They recognized that complex chronic pain could not be successfully treated with a single modality, and that a multidisciplinary approach with psychologists at the helm was the only approach that could help the most refractory cases. How that ideal became corrupted is the story of Keefe’s book. For anyone, including the present authors, who have watched while our chosen field became tarnished by money, it should be obligatory reading. And whether as an exercise in self-reflection, a revelation of what was hidden behind the world we have labored within, or a thoroughly good read, it is a page-turner that you will be glad to have picked up.