Dopesick: Dealers, Doctors, and the Drug Company that Addicted America

by Beth Macy

Drug overdose had already taken the lives of 300,000 Americans over the past fifteen years, and experts now predicted that 300,000 more would die in only the next five. It is now the leading cause of death for Americans under the age of fifty, killing more people than guns or car accidents, at a rate higher than the HIV epidemic at its peak. The rate of casualties is so unprecedented that it’s almost impossible to look at the total number dead—and at the doctors and mothers and teachers and foster parents who survive them—and not wonder why the nation’s response has been so slow in coming and so impotently executed when it finally did.

Three months before visiting Jones, in the spring of 2016, Kristi Fernandez and I stood next to Jesse’s grave on a rolling hillside in Strasburg, Virginia, in the shadow of Signal Knob. She’d asked me to meet her at one of her regular cemetery stops, on her way home from work, so I could see how she’d positioned his marker, just so, at the edge of the graveyard. It was possible to stand at Jesse’s headstone—emblazoned with the foot-high number 55, in the same font as the lettering on his Strasburg Rams varsity jersey—and look down on the stadium where he had once summoned the crowd to its feet simply by running onto the field and pumping his arms.

When I pulled into the cemetery for our first meeting, Kristi had taken it as an omen that my license plate included Jesse’s number, 55. She’s always looking for signs from Jesse—a glint of sun shining through the clouds, a Mother’s Day brunch receipt for $64.55. To her, my license plate number meant our meeting was Jesse-sanctioned and Jesse-approved. Kristi used to think that maintaining Jesse’s grave was “the last thing we can do for him,” she told me, choking back tears. But right now she’s obsessed with the story of her son’s swift descent into addiction—the missing details that might explain how Jesse went from being a high school football hunk and burly construction worker to a heroin-overdose statistic, slumped on someone else’s bathroom floor. If she understood the progression of his addiction better, she reasons, maybe she could help other parents protect their kids from stumbling down that same path.

When a new drug sweeps the country, it historically starts in the big cities and gradually spreads to the hinterlands, as in the cases of cocaine and crack. But the opioid epidemic began in exactly the opposite manner, grabbing a toehold in isolated Appalachia, Midwestern rust belt counties, and rural Maine. Working-class families who were traditionally dependent on jobs in high-risk industries to pay their bills—coal mining in southwest Virginia, steel milling in western Pennsylvania, logging in Maine—weren’t just the first to experience the epidemic of drug overdose; they also happened to live in politically unimportant places, hollows and towns and fishing villages where the treatment options were likely to be hours from home. Jesse Bolstridge was born in the mid-1990s, when opioid addiction first took root. His short life represents the arc of the epidemic’s toll, the apex of which is nowhere close to being reached.

At the moment, she’s AWOL—her mother and I have no idea where she is—although sometimes we catch glimpses of her on our cellphones: a Facebook exchange between Tess and one of her heroin dealers, or a prostitution ad through which Tess will fund her next fix.

I open my notebook, situate the questions I’ve prepared off to the side, next to my spare pens. I’m thinking of Kristi and Ginger and of Tess’s mom, and what Jones might say that will explain the fate of these mothers’ kids. Jones leans forward, expectant and unsmiling, and rubs his hands together, as if we’re business associates sitting down to hammer out a deal. Then he takes a deep breath and, relaxing back into his chair, he waits for me to start.

The story of how the opioid epidemic came to change this country begins in the mid to late 1990s, in Virginia’s westernmost point, in the pie-shaped county sandwiched between Tennessee and Kentucky, a place closer to eight other state capitals than its own, in Richmond. Head north as the crow flies from the county seat of Jonesville and you’ll end up west of Detroit. Geopolitically, Lee County was the ultimate flyover region, hard to access by car, full of curvy, two-lane roads, and dotted with rusted-out coal tipples. It was the precise point in America where politicians were least likely to hold campaign rallies or pretend to give a shit—until the unchecked epidemic finally landed on their couches, too.

Most pain pills lasted only four hours, but OxyContin was supposed to provide steady relief three times as long, giving people in serious pain the miracle of uninterrupted sleep. In an early concession to the potential for its abuse, the makers of OxyContin claimed the slow-release delivery mechanism would frustrate drug abusers chasing a euphoric rush.

Approved by the Food and Drug Administration in late 1995, OxyContin was the brainchild of a little-known, family-owned pharmaceutical company called Purdue Frederick, based in Stamford, Connecticut.

“Since the close of the war, men once wealthy, but impoverished by the rebellion, have taken to eating and drinking opium to drown their sorrows,” lamented an opium dealer in New York.

The Harrison Narcotics Act of 1914 severely restricted the sale and possession of heroin and other narcotic drugs, and by 1924 the manufacture of heroin was outlawed, twenty-six years after Bayer’s pill came to market.

The addicted were now termed “junkies,” inner-city users who supported their habit by collecting and selling scrap metal.

Gone and buried were the doctor-addicted opioid users once common, especially in small towns—think of Harper Lee’s morphine-addicted eccentric, Mrs. Dubose, from To Kill a Mockingbird, or the morphine-addicted mother who inspired Eugene O’Neill’s Long Day’s Journey into Night. Think of the “Des Moines woman [who] gave her husband morphine to cure him of chewing tobacco,” as one newspaper chortled. “It cured him, but she is doing her own spring planting.”

Despite all the technical, medical, and political sophistication developed over the past century, despite the regulatory initiatives and the so-called War on Drugs, few people batted an eye in the late 1990s as a new wave of opioid addiction crept onto the prescription pads of America’s doctors, then morphed into an all-out epidemic of OxyContin’s chemical cousin: Heinrich Dreser’s drug. No one saw the train wreck coming—not the epidemiologists, not the criminologists, not even the scholars who for decades had dissected the historical arc of Papaver somniferum, the opium poppy.

The seismic shift toward thinking of patients as health care consumers was already under way, as patients now rated their health care experiences in formal surveys, Press Ganey the largest among them, and doctors and hospitals alike competed to see who could engender the highest scores, incentivizing nurses and doctors to treat pain liberally or risk losing reimbursements.

“Every single physician I knew at the time was told to be much more serious about making pain a priority,” said Dr. John Burton, the head of emergency medicine for Carilion Clinic, the largest medical provider in western Virginia. “All it did was drive up our opioid prescribing without really understanding the consequences of what we were doing. “I can remember telling my residents, ‘A patient can’t get hooked on fourteen days’ worth of [opioid] pills.’ And I was absolutely wrong.”

Compared with the New Zealand hospitals where Davis worked earlier in his career—often prescribing physical therapy, anti-inflammatories, biofeedback, or acupuncture as a first-line measure—American insurance companies in the age of managed care were more likely to cover opioid pills, which were not only cheaper but also considered a much quicker fix.

Van Zee sounded the alarm about OxyContin just as its makers were on the threshold of grossing its first billion on the blockbuster drug. And though he didn’t yet know it, he would spend the remainder of his career dealing with its aftermath—lobbying policy makers, treating the addicted, and attending funerals of the overdosed dead.

In an Appalachian culture that prides itself on self-reliance and a feisty dose of fatalism, peddling pills was now the modern-day moonshining. Some passed the trade secrets down to their kids because, after all, how else could they afford to eat and pay their bills?

The parent meeting had been a setup. Whereas Van Zee thought the company might finally be willing to make some compromises—“Art…really thought Purdue would feel some empathy” toward the banker, Sue Ella recalled—it was plain now that was not the case. The meeting had been brokered to shove the ad down the group’s throat. Sue Ella blew up, telling Haddox: “You have done more to hurt Appalachia than the coal industry has ever thought about doing.”

Over the years, Sue Ella’s and Sister Beth’s lives had been threatened because of their social activism, including once when Beth convinced an illiterate coal miner not to sign away all company liability for a mining accident. (“Greed makes people violent,” she told an interviewer in 1982. “When we stand with the least in the struggle for justice, there’s a price to pay.”) The Purdue offer was just another page in an old story. This is what happens when wealthy people think they own you, Sister Beth told her Lee County friends. Since the first piece of coal was chiseled from the first mountainside rock by a large out-of-state corporation, the region had suffered from a pattern of exploitation, she said, ticking off all the mining-company executives who’d flown in over the years and spread their money around trying to buy peace, and then shut down unions, reduced black-lung benefits, and kept other industries out to maintain low labor costs.

She recalled the first phone call she’d taken about the drug, in the late 1990s. The informant had told the cop. The cop called the pharmacist. The pharmacist called Sister Beth. It was another game of telephone, only this message remained tragically on point: “Beth, you wait,” pharmacist Stewart had told her on the phone. “They’re saying it’s nonaddictive, but you mark my words: This is the beginning of a disaster for us.” The disaster was now in full bloom. And Sue Ella and Sister Beth guessed exactly where it was headed. Even if Big Pharma and the pill-mill doctors could be brought to justice, the morphine molecule was so deadly, its lure so intractable, that those who were already addicted were likely to be ruled by it for the rest of their lives.

Although a decade later Portenoy conceded to Wall Street Journal reporters that he and other pain doctors had mistakenly overstated the benefits of opioids while discounting their risks, back then Van Zee was the doctor whose judgment was questioned and even mocked. “A lot of people discounted Art as a rabble-rouser and a kook,” a prominent Virginia health care administrator explained. Another parent activist suggested that Van Zee’s uncomfortable and slightly disheveled appearance helped Purdue cast him as a kook rather than the groundbreaking physician he was. “He should’ve gotten the Nobel Peace Prize,” she said.

Van Rooyan was never against the use of OxyContin for terminal pain but argued that it should not be used for chronic, noncancer pain unless all other treatments have first been explored.

If the federal regulators weren’t moved by memorials to dead Americans from their grieving mothers and fathers, maybe the country doctor and the nun and their growing team of mourning parents would finally get justice from the courts. At minimum, they hoped to amplify Purdue Pharma’s negative press and raise awareness about the heroinlike drug.

To help burnish its image in the face of so many legal, financial, and public-relations problems, Purdue hired former New York mayor and Republican insider Rudy Giuliani and his consulting firm, Giuliani Partners. Just a few months after his lauded response to the 9/11 terrorist attacks, Giuliani’s job was to convince “public officials they could trust Purdue because they could trust him,” as Barry Meier and another writer at the New York Times put it.

“You’re not gonna believe this, but Ed had to take your son out of the courthouse.” Purdue’s lawyers had heard about the urn and asked the judge to have it removed from the building. Bisch and White expected the grieving mom to blow up, but Nuss surprised them by laughing instead. She told her friends, “My son is not here in body, but he is definitely here in spirit. “He might have left the building, but he will be back!”

During the first decade of the drug’s existence, the legal system could not prove the makers of OxyContin had broken the law.

Their clients ranged from miners and masonry workers who became addicted following work-related injuries to a factory worker so desperate to stop taking OxyContin that he’d flushed his pills down the toilet, telling his lawyer that trying to explain dopesickness to a nonaddict was “like describing an elephant to a blind man.”

In the fall of 2006, Purdue’s lawyers began to sense that this case against them was different; that a full-court press meant nothing when the opposing counsel was the United States of America. Was it really possible the small-town lawyers had compiled enough evidence to indict both the company and its top executives on a host of felony charges, not just for misbranding the drug but also for mail fraud, wire fraud, and money laundering? It seemed so, according to a memo written by the federal prosecutors to Brownlee at the time.

the night before the plea agreement was set to expire—after which the company would face charges—when a senior Justice Department officer phoned Brownlee at home (at a Purdue lawyer’s request), urging him to extend the deadline to give Purdue more time. Brownlee was through being pressured. The lobbying and negotiations had gone on long enough. The clock had all but run out. Rather than risk more serious charges or a jury trial in western Virginia, where the drug’s problems were by now legend, the company accepted the plea agreement later that night. But Purdue wasn’t quite finished negotiating. Eight days after it accepted the deal, Brownlee was stunned to see his name on a firing list, along with four other U.S. attorneys. Though he wasn’t ultimately fired, the incident provided fresh criticism of then–attorney general Alberto Gonzales, accused of trying to sway the work of U.S. attorneys’ offices.

The Sacklers understood that a federal jury convened in southwest Virginia, a region that had now seen as many as two hundred OxyContin-related deaths, could have awarded far harsher penalties. “We weren’t just trying to get a little bit of money from them. The goal was to stop the criminal behavior, punish it, and to strip them of their profits,” the negotiator said.

Brownlee enjoyed presenting his evidence at the press conference, unfolding his podium against a staggering backdrop of documents amassed by Gregg Wood, the stoic prosecutors Randy Ramseyer and Rick Mountcastle, and scores of others recruited to the team—all of whom stood to his right. To his left sat an assortment of evidence culled from the two thousand cardboard containers they’d filled with documents, depositions, and data. The boxes were lined up in columns four to five feet high. For added visual effect, Brownlee displayed falsified charts created by Purdue that had claimed “smooth and sustained blood levels” and “fewer peaks and valleys” for patients on OxyContin.

It had all come from the Shadow Company’s “Warehouse,” as the prosecutors called it. The hillbilly lawyers had filled so many boxes with evidence that Brownlee had to rent extra space in an Abingdon strip mall to hold them all.

More than a decade later, as journalists and policy makers tried to pinpoint where and how the opioid crisis began, images from the rainy rally in Abingdon would get recycled in news accounts, the prescient parents marching with their signs, and next to them Sister Beth standing defiant, a look on her face that projected equal parts anger for what had happened and worry for what was coming next.

“I think jail is too good for you guys,” said Lynn Locascio from Palm Harbor, Florida. Her son was still struggling with addiction, having been prescribed OxyContin after surgery resulting from a car accident. “I think you should go spend some time in a rehab facility like my son did and watch that. Maybe you’ll change your minds.”

And while that is exactly what their lawyers did, Ramseyer later said the men seemed distressed throughout the proceedings. “They were very unhappy,” he told me. “We do cases in court where people get sentenced to twenty or thirty years in prison, and they didn’t seem as unhappy as those three guys.”

He’d read recently that enough opioid painkillers had been prescribed in 2010 to medicate every American adult around the clock for a month. “And it’s worse now,” he told me in 2016.

What in fact was the addiction rate among those prescribed opioids for chronic nonmalignant pain? More recent studies—not letters to the editor penned in 1980—put the figure as high as 56 percent.

Arthur Sackler hated not just bad press but any press that was not of his own directing, a Vanity Fair writer observed shortly after his death. As obsessive about secrecy as he was about moneymaking and art, he would have abhorred everything about the Abingdon hearing.

Van Zee and Sister Beth viewed the settlement with both satisfaction and regret. Though the executives were placed on probation for three years and ordered to perform four hundred hours of community service in a drug abuse or drug treatment program, Van Zee and Sister Beth were furious that the Purdue fine would not be allocated to provide drug treatment in the medically underserved region. “This little county was left with nothing, even though we’ve been disproportionately impacted” by the drug, Sister Beth said. The $634.5 million fine was instead divided among law enforcement, state, and federal Medicaid programs (to reimburse it for claims resulting from the misbranding); to create Virginia’s Prescription Monitoring Program; and to settle $130 million in civil claims. The only thing the Lee County sheriff’s office got from Purdue was placebo OxyContin pills for use in drug stings.

If the Sacklers’ lieutenants had legitimately not known about the flood of pills unleashed by sales reps toting around bad data and free shrubbery twenty-five rungs down the corporate ladder from them, maybe it was because they had not cared to look.

“The opioid epidemic is an urban story, a suburban story, and a rural story,” said Dr. Jennifer Wells, a Roanoke addiction specialist who has patients from each of these demographics, including one mom with five kids in a countryside trailer and no running water who somehow manages to make it to her group therapy meetings every week. “Roanoke is just big enough where all the stories meet.”

Before the weathermen incident, heroin had been the domain of police and court reporters in Roanoke, widely believed to be an inner-city (read: black) drug. “In the ’80s and ’90s, maybe a few dozen people were doing heroin here,” said Don Wolthuis, the assistant U.S. attorney who became one of the federal government’s top heroin prosecutors in the state’s western half. “Because heroin is a depressant, people kind of withdraw; they go in a corner, shoot up, and sit there in the dark, in a fetal position. They weren’t out there committing crimes like with crack or meth. It was a largely invisible and isolated group.”

The growth in heroin users was as exponential as its 600 percent profit margin. The first bags sold in Roanoke were stamped with the names Funeral and Green Frog, and some had a purity of 90 percent, a concentration that addicted users quickly and made the dosages deadlier.

The story of Clifton Lee and the addicts he serviced and created didn’t trickle down to me at the newspaper, where I wrote about family issues, until 2010. That year, the region’s only heroin-overdose death made headlines, not because it was unique but because it involved the twenty-one-year-old son of a prominent white businesswoman.

I talked to my older son about heroin so much that one of the last things he said to me when we dropped him off at college that fall was “I know! Don’t do heroin!” He rolled his eyes with an annoyance reserved for the exceedingly daft.

As his counselor Vinnie Dabney remembered it, “Fifteen rehabs had not convinced Spencer that it was not in his best interests to get high. It took time in jail and a friend dying before he could decide he wanted to change.”

For people who have not ventured recently into rural America, the jaw-dropping and visible decline of work comes as a shocker, an outgrowth of the nation’s widening political and cultural divide. Before the 2016 election of Donald Trump, that disconnect was maintained by a national media that paid little attention to rural, predominantly white places like St. Charles or Bassett, where the country’s much-hailed economic recovery had definitely not trickled down. At the same time, it had never been within the purview of local papers like the Martinsville Bulletin to investigate what was happening with international trade in Washington or New York, much less the latest push by Big Pharma or global drug cartels. And regional newspapers like my own Roanoke Times had drastically shrunk their coverage to a mainly urban and suburban core, ignoring the increasingly distressed communities in our hinterlands just when reporting on those places was needed the most. Those of us living highly curated and time-strapped lives in cities across America—predominantly mixing virtually and physically with people whose views echoed our own—had no idea how politically and economically splintered our nation had become. And also how much poorer and sicker and work-starved the already struggling parts of the nation truly were—because we didn’t follow that story. We may feel more connected by our cellphones and computers, but in reality we are more divided than ever before.

A scrawny junkie with sunken eyes and sticky-out collarbones, as Spencer described himself to me in 2012, “I looked ridiculous, like I had chicken pox. Like I’d stuck my head down a groundhog’s lair.” But I had failed, just as the police and parents had, to connect young adults like Spencer to the rural addicted, even though Spencer told me he’d come to his heroin addiction the same way they had—through prescription opioid pills.