The “opioid epidemic” has been front-page news for some time now. Twenty-two thousand people in America died of overdoses from opioids in 2015. Just two years later that number was 49,000, enough to reduce the average lifespan in the United States by 0.1 percent when combined with suicides. Dopesick, a new book by Beth Macy, gives an account of the origins of the epidemic, focusing on the lives most affected—the addicts and their families.
There have been several other recent books that cover this topic, including Pain Killer by Barry Meier and the excellent Dreamland by Sam Quinones. What sets Dopesick apart is that Beth has an intimate view from her home in Roanoke in western Virginia—at the epicenter of the crisis. She clearly has close relationships with many young addicts as well as their families. She follows Spencer, a high school football player who went to private school before becoming addicted to pills and then heroin. She chronicles his fifteen stints in rehab as well as his preparations for jail time. We also learn about Jesse, a high-energy construction worker who died from an overdose the day before entering another rehabilitation program. Jesse’s mother Kristi became obsessed with his story, following his friends and dealers in order to understand his rapid descent into addiction.
For those not familiar, “opioid” is a catch-all term for medications derived from the opium poppy, such as morphine, codeine, and heroin, as well as synthetic derivatives which are usually much more potent, such as the drug fentanyl. These medications have been used for thousands of years to treat otherwise untreatable pain. The unwanted side effects of opioids have also been long recognized—they cause intense euphoria and desire for repeated use. Long-term users need increasingly larger doses to treat pain and prevent withdrawal, an intensely unpleasant syndrome that includes nausea, diarrhea, muscle aches, and a nearly uncontrollable craving for more drugs.
The book introduces Purdue Pharma, a little-known pharmaceutical company until the 1996 release of Oxycontin, a form of the synthetic opioid oxycodone, approximately as potent as intravenous morphine. Purdue’s innovation was to cover the drug with a thin film in order to control its release into the body, giving it a longer duration of effect and purportedly reducing the risk of addiction.
The introduction of Oxycontin coincided with a change in attitude in the medical community to the treatment of pain. Prescribing of opioid pain medications went from being a rare event reserved for end-stage cancer patients to being prescribed for broken bones, tooth pain, or common aches and pains. Purdue both benefited from this change and was instrumental in effecting it. Purdue took part in writing prescribing guidelines, and then distributed them widely. Aggressively marketing Oxycontin, Purdue deployed an army of drug salespeople who handed out meals, all-expense paid trips, and endless propaganda about Oxycontin’s safety, effectiveness, and low risk of addiction. Salespeople specifically targeted doctors who prescribed the most Oxycontin, ensuring that sales increased. And they did, from $1 billion in 2000, to double that only three years later.
In fact, Oxycontin is both highly addictive and easily abused. The much-touted protective coating can easily be rubbed off, or the pills can simply be chewed, or crushed and snorted. These facts were immediately apparent to anyone who bothered to look, including law enforcement, health-care providers, and Purdue salespeople, some of whose stories are told in Dopesick. The abuse and addiction to Oxycontin in the late 1990s is the root cause of our current opioid crisis.
The first section of the book ends with the successful lawsuit against Purdue Pharma and three top executives. In 2007 they pled guilty to misleading regulators, doctors, and patients to the true risk of addiction to Oxycontin. The company was fined $600 million, which at the time was a record, although the amount represented only a portion of the profits made from the sale of the drug. The executives pled guilty to felonies, but were given only community service.
The second section of Dopesick largely chronicles the spread of Oxycontin and addiction from rural Appalachia to suburban areas, and from poor to middle and upper-class addicts.
Most of the initial abuse of Oxycontin impacted poor whites in rural Appalachia. That is where “pill-mills’” were introduced, “clinics” where a “patient” could get a prescription for large amounts of Oxycontin from an unscrupulous doctor for a set cash amount, and then fill it at a nearby pharmacy. Opioids spread quickly in communities devastated by factory and mine closures, providing both an escape from hopelessness and an income from selling excess pills.
Widespread addiction among poor whites in remote areas could be easily ignored. But the plentiful supply of pills, obtained easily through legal prescription and illicitly, quickly spread to other areas. Starting in the early 2010s, more and more middle-class suburban white youth were becoming addicted, and these users quickly moved from prescription Oxycontin to more potent and cheaper street heroin.
In the third section, Macy explores the broken addiction-treatment system in the United States. Macy follows Tess Henry and her infant son through a series of failed rehabilitation attempts with insufficient insurance and little money. Like many people addicted to opioids, Tess’s struggles revolved around not only paying for treatment, but also finding programs that allow methadone or suboxone in addition to therapy, called medication-assisted treatment or MAT. Buprenorphine or methadone are extremely long-acting opioids that allow patients in treatment to take once-daily dosing in order to avoid withdrawal symptoms. Buprenorphine allowed Tess to “feel normal.” Insurance covered most of the medications, but visits to the prescriber were cash only, costing up to $100 per visit, with up to four visits per month. Despite the cost, there is normally a long waiting list for these clinics, as MAT has markedly better outcomes and is often the only type of therapy that a loved one will accept. But most inpatient treatment programs will not accept people on MAT, adhering to a moralistic abstinence-only philosophy, despite the evidence of the benefits of MAT.
Dopesick ends in January 2018 with the tragic death of Tess on the streets of Las Vegas. If there is a happy ending, it is in recent newspaper headlines. The Guardian published a story in November about a wave of lawsuits from cities and states across the country that specifically name the Sackler family—the owners of Purdue Pharma—as well as Purdue itself. In recent decades the Sacklers have been busy whitewashing their name by spending their billions on art and museums. There is a Sackler wing at the Metropolitan Museum in New York, as well as at the Guggenheim, the Victoria and Albert Museum in London, and at many other institutions. Hopefully these lawsuits will instead fund treatment for those impacted by their family business.