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

by Beth Macy

Cantrell remembered setting up a mobile clinic in the parking lot of the Buster Brown apparel factory in the early 1990s because the women who worked there did piecework—they were paid by the number of sewn pieces they produced—and they had zero sick leave. “They couldn’t leave work to have a pap smear or a breast exam, so we took the clinic to them,” Cantrell recalled.

Jobs in coal mining, once the number-one industry in central Appalachia, were cut in half between 1983 and 2012, owing to pollution regulations and competition from natural gas and cheaper low-sulfur coal out west. Automation in mining and the closings of factories that burned coal for power also contributed to the region’s decline.

Van Zee seemed to have all the time in the world for his patients, never mind that he worked sixteen-hour days, rising at four in the morning to type up his patient notes from the previous day’s visits. A doctor who’d trained in Philadelphia recalled working with Van Zee during medical school and residency: “We’d rotate in and out of these big medical centers, and when we’d get back to school, it would occur to us, ‘The best doctor in America is actually out in Lee County, Virginia,’” he told me.

Down the hall from his office, a physician colleague treated a septuagenarian farmer who had owned land worth $500,000. Within six months, the man had sold everything he had to keep his addiction fed. “It’s over,” he told his doctor. “The kids are gone. The wife’s gone. The farm’s gone.”

“The difference with OxyContin was, it turned them into nonfunctioning people.”

“Nobody would listen to her,” said Dr. Molly O’Dell, then a fellow health-department director several counties to the east. “But she was right there in the epicenter of where the pills started. She’s the first person I ever heard to name it. She called me and said, ‘Molly, I think we’ve got an epidemic down here.’”

They have discussed that defining moment a lot in the intervening years. They’ve wondered aloud what might have happened had her gallbladder not given out at the same time the factories and mines were laying off and shutting down.

She might not have found herself doubled over and dopesick the day her prescriptions ran out. “You’re throwing up. You have diarrhea. You ache so bad and you’re so irritable that you can’t stand to be touched. Your legs shake so bad you can’t sleep. You’re as ill as one hornet could ever be,” she recalled. “And believe me, you’ll do anything to make that pain go away.”

She’d leave with a prescription for Percocet. She was a full-blown opioid addict when she resorted to stealing the money her husband set aside for paying the electric bill and spending it at the office of a well-known Lebanon doctor who began most of her visits to him with the question “What do you want?”

The Board of Medicine suspended Dr. Dwight Bailey’s license to practice medicine in 2014 for excessive prescribing and poor record keeping, noting that five patients had died from drug overdoses while under his care—but that was more than a decade after Honaker first came through his doors.

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?

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Honaker put in: “At the end of your journey, you’re not going after drugs to get high; you’re going to keep from being sick.”

Within two years of the drug’s release, 24 percent of Lee High School juniors reported trying OxyContin, and so had 9 percent of the county’s seventh-graders.

And though OxyContin’s initial converts in Maine were fishermen and loggers, not coal miners, the results were the same: People were “walking” prescriptions, or stealing prescriptions pads the moment a doctor turned his or her back. They were “shopping,” too—quietly soliciting concurrent prescriptions from multiple doctors. Selling prescribed pills, available for a pittance with an insurance or Medicaid card, was now seen as a viable way of paying your bills in a county where the unemployment rate hovered around 22 percent.

Opioid addiction is a lifelong and typically relapse-filled disease. Forty to 60 percent of addicted opioid users can achieve remission with medication-assisted treatment, according to 2017 statistics, but sustained remission can take as long as ten or more years. Meanwhile, about 4 percent of the opioid-addicted die annually of overdose.

Unemployed Tazewell miners like Doug Clark, who’d once made thirty-five dollars an hour, were now in legal trouble for ripping copper from an abandoned mining-equipment shop—to resell on the black market and fund his next OxyContin buy. Clark had gotten hooked after surgery to repair an injured neck and broken jaw; a rock had fallen on him inside a nearby Russell County mine, since closed.

Van Zee didn’t yet grasp what was truly driving the furious rate of overprescription. Sales-rep bonuses were growing exponentially, from $1 million in 1996, the year OxyContin hit the market, to $40 million in 2001. New patients were given OxyContin “starter coupons” for free prescriptions—redeemable for a thirty-day supply—and Purdue conducted more than forty national pain management and speaker-training conferences, luring doctors to resorts from Boca Raton, Florida, to Scottsdale, Arizona. The trips were free, including beach hats with the royal-blue OxyContin logo. More than five thousand doctors, nurses, and pharmacists attended the conferences during the drug’s first five years—all expenses paid.

“The doctors started prostituting themselves for a few free trips to Florida,” recalled lawyer Emmitt Yeary from nearby Abingdon, Virginia.

God help us

“The irony of it was, the victims were getting jail time instead of the people who caused it,” Yeary recalled.

He remembered a dislocated coal miner from Grundy, Virginia, confessing that OxyContin had become more important to him than his family, his church, and his children. “It became my god,” the man said.

At the Lee County jail, seventy-nine people were crammed into cells designed to hold thirty-four. “We were so overwhelmed, we were just stacking ’em on the floor,” the sheriff, Gary Parsons, told me; one of the prisoners had bought four OxyContin tablets by trading away his family’s mule.

In small towns where residents were used to leaving their doors unlocked, patrol officers were suddenly seeing people pushing stolen lawnmowers, four-wheelers, and even garden tillers down the street.

A man in Dryden killed a young man attempting to break into his house to steal his wife’s prescription drugs, which he’d spotted above the kitchen-sink windowsill—down the road from Van Zee’s house.

“There is literally not a family in this county that has not been impacted by this drug,” he told me in 2017, a statement I heard in every Appalachian county I visited.

Another set of scales fell from the doctor’s eyes as a distinct possibility flashed before him: No one in federal government would take seriously the concerns of a country doctor until opioid abuse took hold in the cities and suburbs. “If it’s a bunch of poor folks up in the mountains, it doesn’t affect them personally,” he said.

When Stewart filled OxyContin prescriptions, he begged his customers to lock their medication up. He’d already been the victim of two robbery attempts, including one by the son of a neighboring hair-salon owner who crawled in through the ceiling vents connecting the salon to Stewart’s store.

Sue Ella explained that she was initially for accepting the money “because of my experience with the coal companies taking and taking and taking, and all the companies, they sit up north with their inherited wealth and leave nothing behind except broken bodies.”

If the Purdue executives thought that people like Sue Ella and Sister Beth could be bought, they had not done their homework. Both had stood on the picket lines with strikers and their families for nine life-and-death months in 1989, when the Pittston Coal Company wanted such huge union-contract concessions as reduced pay-in to retired miners’ health insurance and wage cuts. Sister Beth had literally lain on the ground, to block the coal trucks, while Sue Ella stood next to the striking miners with her six-month-old baby in a carrier.

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.”)

She thought about the high school senior, a cheerleader, snorting OxyContin in the school library. About the people having their teeth pulled for the sole purpose of eliciting an Oxy prescription from a dentist. About the middle-aged woman who’d ruefully remarked in the middle of being fingerprinted and photographed that she was wearing the same gray sweatpants she’d had on the last time she was arrested for distributing OxyContin.

“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.”

Sister Beth threatened to quit the coalition if anyone accepted Purdue Pharma’s $100,000 grant, and Van Zee’s letter of acceptance was never sent. The grant was nothing more than “blood money,” she said, and the coalition agreed.

As friends gathered, Bisch was still in shock and grappling for answers when he asked the first responders what his son had taken. “Oxy,” one said. “What the hell’s an Oxy?” Bisch wanted to know. The first time Ed Bisch heard the word “OxyContin,” his son was dead from it.

By the 1920s and 1930s, most of the small-town morphine addicts and Civil War veterans with soldier’s disease had died out, not long after the national crackdown hastened by the Harrison Narcotics Act, which set the scene for drug prohibition and, later, the so-called War on Drugs.

For most of the previous century, opioid addiction was mainly relegated to big northeastern cities, where heroin had long been smuggled in through illicit channels, infiltrating the Harlem jazz scene of the 1940s and the beatnik subculture of the 1950s. The term “hipster,” in fact, drew from the Chinese opium smoker of the 1800s, who’d spent much of his time smoking while reclining on one hip.

Progressive doctors championed the carefully restricted use of narcotics and called out heavy prescribers for being behind the times. Pharmacists, too, upped the refill bar so high that in 1955 the heroin-addicted Beat writer and artist William Burroughs called them “sour, puritanical shits,” unlikely to fill even a codeine prescription without checking with the doctor’s office first.

But when doctors started widely prescribing OxyContin for noncancer pain in the late 1990s, it effectively nationalized the supply, making opioids no longer only a big-city story. “So that any doctor in any small town, under the dispensation of a new FDA-approved prescription, could now suddenly provide opioids to people with low back issues and so on. You read a lot about economic depression and loss of morale, and I’m certain that fuels the epidemic. “But the supply expansion [via OxyContin] came before anything else. And if it hadn’t been for the supply expansion, then this [epidemic] would not have happened,” Courtwright said.

If history was any indication, the moment OxyContin and other opioid pills became too expensive or too cumbersome to get, illegal drug peddlers would step in to fulfill the market demand, just as they had done a century earlier when heroin became illegal.

Parents from Florida to California joined Bisch in memorializing their dead children on his site, which became a running tally of dead athletes and young mothers and former beauty queens, many no more than twenty years old. “I was answering every email, and it was consuming me,” Bisch recalled. “Probably ten deaths a day, sometimes a hundred emails a week.”

If OxyContin nationalized the opioid supply chain, Nuss and Bisch nationalized the opposition to it, launching a grassroots nonprofit called Relatives Against Purdue Pharma (RAPP).

Sue Ella admired the way her mild-mannered husband was stifling his hardwired passivity to stand up for the region, yet she increasingly resented the time it took away from their family life. “We used to try to go a day without saying the words ‘addiction’ or ‘OxyContin,’ but we never made it, not once,” she said.

Though Purdue claimed it had no idea of the drug’s abuse problems until February 2000, Wright had signed off on a 1995-filed NDA review that spelled out how crushing the tablets would lead to immediate, rather than controlled, release of the drug; that withdrawal symptoms had been witnessed in several patients during clinical trials; and that 68 percent of the oxycodone was in fact recoverable from one single, crushed-up pill when liquefied and injected.

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.

But it was clear as early as 2004 to Van Rooyan, then a researcher, professor, and college counselor, that the FDA failed to protect the public, her son included, not only when it approved the drug but also multiple times thereafter.

It would not come to light for nine more years that FDA regulators and Big Pharma executives had been quietly holding private meetings at expensive hotels at least annually since 2002, through a drug-industry-funded nonprofit, an ethical quandary a Milwaukee Journal Sentinel reporter shone the light on in 2013. The meetings led to the development of “enriched enrollment,” an aptly named practice that allowed drug companies to weed out people from their studies who didn’t respond well to their drugs, therefore tipping the balance toward FDA approval of new drugs—and away from science.

The same Journal Sentinel reporter, John Fauber, would also uncover how the American Pain Society and the American Academy of Pain Medicine pushed for expanded use of opioids for long-term chronic pain while taking in millions from the companies that made them.

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.

“It is clear to us, and we hope it is clear to the government, that Giuliani would not take an assignment with a company that he felt was acting in an improper way.” After all, not only was Giuliani old pals with the DEA director, but he also had just been named Time magazine’s Person of the Year 2001.

White’s attorney named two specific doctors she was urged to call on who were widely known for overprescribing. Both eventually lost their medical licenses for shoddy prescribing, including one who’d handed out prescription drugs in exchange for sex.

The jury ruled in favor of Purdue, whose lawyer called the case a “personal disagreement with promoting the drug in an entirely legal way.” While White believed calling on sleazy pill prescribers was illegal, her lawyer had not proved the illegality of the company’s sales strategies. “The court basically said, ‘Don’t tell us what you believe. Tell us what you know,’” explained University of Kentucky legal scholar Richard Ausness, who has written about the difficulty of winning civil cases against Purdue, citing among other reasons the company’s hefty defense chest.