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

by Beth Macy

an Onion-style medical parody on a website called GomerBlog, which punchy health care workers across the state had gleefully called to my attention: “To kick off their new labeling, [the Dilaudid-making] company hopes to change the pain scale from a 0–10 to Tylenol-to–That One That Starts with a D,” the satirist wrote. (“You go crazy if you can’t laugh every now and then,” a nurse-practitioner told me.)

During the six months Lutz was away from his usual drug beat, heroin exploded in his tiny, bucolic community—three people died of overdose, and the hospital would soon report its first opioid-dependent baby. “How it transformed from a pill problem to a heroin problem here, it was like cutting off and on a light switch,” Lutz recalled.

Lutz called in federal reinforcements when he heard that D.C., whoever he was, was in the habit of demanding sex from female addicts before he’d sell them their dope. Informants said at least one was a teenager.

One woman he knew was in the habit of kissing her husband goodbye in the morning, putting her kids on the school bus, then driving to Baltimore to buy enough to last the day before returning to Woodstock just as the school bus brought her kids home.

Whereas central Appalachian communities like Lee County—victims of factory and coal-mine shutdowns, followed by skyrocketing disability claims that made them prime sales targets for Big Pharma—had been battling opioid addiction since OxyContin’s 1996 release, Woodstock and similar small towns were slower to experience deaths related to opioid addiction, alcohol-related liver disease, and suicide. They seemed to be somewhat shielded because their economies, while not exactly robust, had maintained a centuries-old agricultural base and were never dominated by a single industry or two like so many smaller Appalachian counties where pill abuse first took root.

More significantly: The opioid-prescribing rate in the Woodstock region was almost half the state’s rate—and less than one-third the rate of opioid prescriptions in the coalfield counties. On average, every person enrolled in Medicare Part D in Lee County had been handed a whopping 10.23 opioid prescriptions in 2013, compared with just 2.96 in Shenandoah County.

The real perfect storm fueling the opioid epidemic had been the collapse of work, followed by the rise in disability and its parallel, pernicious twin: the flood of painkillers pushed by rapacious pharma companies and regulators who approved one opioid pill after another.

As Monnat put it: “When work no longer becomes an option for people, what you have at the base is a structural problem, where the American dream becomes a scam.”

She likened the epidemic’s spread not to crabgrass but to a wildfire: “If the economic collapse was the kindling in this epidemic, the opiates were the spark that lit the fire.”

With the highest per capita rate of heroin use in the country, Baltimore residents were six times more likely to die from an opioid overdose than the national average.

A 2017 New Yorker profile of Martinsburg by Margaret Talbot opened with the synchronous thud of two Little League parents who had fallen from the bleachers after overdosing at their daughter’s softball practice, their younger children running around and frantically screaming, “Wake up! Wake up!”

Martinsburg wv

“The drug dealer’s dilemma is always: How do I market myself and remain invisible simultaneously?”

When Jones or his runners went to New York to resupply, Marie later told investigators, “two hundred people I know of would get sick [go into withdrawals]. They could not wait for Jones to get back, and when he got back, everybody was better.”

“You can’t blame Ronnie for everything,” Marie told me. “We’re the ones who stuck the needle in our arms. But we didn’t have heroin available to buy here in town till Ronnie came. What he did ruined a lot of people’s lives,” she said, ticking off a long list of names.

“We were starting to have eighteen-year-olds overdose,” Lutz remembered. “We were disgusted with what he was doing to our town.” Before 2013 was over, overdose deaths in the region would surge to twenty-one, up from a single death in 2012.

Heroin was so wildly lucrative that even mid-level dealers in the ring could make $15,000 in a single weekend.

In a letter from a North Carolina prison, Marshall himself wrote: “I’ve done tree work, tended bar, did graphic design for a studio up in Manhattan, among other jobs. I’ve had 20 grand stashed in my house for the re-up, and I’ve lived in a tent in the woods because I was so far gone on dope.”

“Jones and Shaw were living the life, but almost everyone underneath them, Keith Marshall included, were junkies distributing just to supply their own habit.”

At the Lakeview raid, Lutz and his colleagues arrested Marie instead, along with four others near the bottom of the FUBI chart. Marie spent seven months in the county jail on charges of heroin possession, a probation violation from an earlier, Suboxone-distribution charge, and child endangerment. “My daughter, she’s seven now, and she still has bad dreams about the night the cops kicked in our door,” she told me in 2016.

Jones had been bringing bulk heroin to Woodstock for exactly six months. During that time, not only had overdose deaths surged but so had nonfatal overdoses, the number of children entering foster care due to parental opioid abuse, and the cases of children born with neonatal abstinence syndrome—all at roughly five times the previous year’s rate.

Chapmanville was, in retrospect, another perfect breeding ground for the opioid epidemic, with OxyContin moving in just as most of the mines were shutting down in the late 1990s, and the only viable economic option—beyond disability and illicit drug sales—was joining the military, one that Metcalf took.

“I distinctly remember teachers skipping entire chapters in textbooks because ‘you will not need this when you are working in the mines,’” he told me in late 2016. It took precisely one visit to an active low-coal mine for Metcalf to understand that his future wasn’t at the bottom of one.

The next county over, in tiny Kermit, West Virginia, Charleston Gazette-Mail reporter Eric Eyre had just won a Pulitzer for pointing out that Big Pharma shipped nearly nine million hydrocodone pills to a single pharmacy in a town of just 392 people, giving Mingo County the fourth-highest prescription opioid death rate of any county in America.

His desire wasn’t just to be a big-time heroin dealer, Metcalf believed. It was also “about money. Control. Manipulation. He created a market that didn’t exist before, then he manipulated it to increase his profits. And that’s the problem with heroin, and why I don’t think it’s going away: The money is insane, and the customers are always there.”

One low- to mid-level dealer ended up with a five-year sentence for selling the equivalent of between 6,400 and 14,400 needles’ worth of dope.

From his perch in the U.S. attorney’s office in Roanoke, the same office that prosecuted Purdue Pharma, he’s indicted heroin dealers for decades, long enough to witness the transition from a small, fairly quiet group of mostly black and middle-aged users in the mid-1990s to a much larger, younger, and whiter group.

One of his first death cases involved a thirteen-person conspiracy brought to his attention when police found a middle-aged woman slumped over on a chair inside her apartment door, shortly after she’d shot up in the bathroom of a Kentucky Fried Chicken. “She was sitting on a claw hammer when [the officers] found her; they’d just left her there all alone to die.” Her friends had propped her up in the chair, he remembered, placed atop the randomly discarded tool.

Another woman prosecuted in that same heroin conspiracy sent her child to the door to deliver the heroin because she was nodding ou...

“There’s just something so fundamentally soul-sucking about her...

And unlike Jamie Waldrop, the Roanoke mother and surgeon’s wife, Kristi could not afford to spend thousands sending her son immediately to another rehab, or flying with him to make sure the transfer stuck.

As National Institute on Drug Abuse (NIDA) director Nora Volkow told me in January 2016: “To be clear, the evidence supports long-term maintenance with these medicines in the context of behavioral treatment and recovery support, not short-term detoxification programs aimed at abstinence.”

Suboxone, etc

“The whole system needs revamped,” said Tracey Helton Mitchell, a recovering heroin user, author, and activist. “In the United States, we are very attached to our twelve-step rehabs, which are not affordable, not standardized from one place to another, and not necessarily effective” for the opioid-addicted.

“What happens is, it takes about eight years on average, after people start treatment, to get one year of sobriety…and four to five different episodes of treatment” for that sobriety to stick. And many people simply don’t have eight years.

And yet Kristi still didn’t comprehend the depth of her son’s addiction. “I hate to even say it, but I thought he was going back to rehab for ‘just pills.’” Jesse still looked like a linebacker, after all. He was handsome and tanned. He hadn’t missed a day of work at his construction job.

How could someone who looked that robust be addicted to heroin?

The region’s pill problem had become a full-fledged heroin epidemic in the span of just a few months.

Some friends quickly fled, chucking the drugs and the paraphernalia into the woods beside the house. Courtney was one of them. She said she ran because she feared her children would be removed by social service workers. (She does not do drugs, she said, and her kids had been asleep in an upstairs bedroom throughout the party and were not exposed.)

Unbelievably irresponsible to host drugged up parties with kids in the house

Jones and Santiago were right, of course. Shit did not stop. That’s not the way addiction works. That’s not typically how prison reentry plays out. It didn’t stop when Dennis Painter’s father moved heaven and earth to get him into treatment again in the wake of Jesse Bolstridge’s death—only to have him continually push through the revolving door of rehab, relapse, and jail.

Dennis described the problem exactly as Metcalf had: If OxyContin had been the economic driver in the Appalachian coalfields, then the heroin highway to Baltimore had become one of the few avenues left for America’s small-town working class.

Can’t get a job in a factory? Drive to Baltimore instead. An investment of $4,000, or 50 grams of heroin, could earn a person $60,000 in a single week.

That’s what happens when rural America becomes the new inner city, ranking dead last behind cities, suburbs, and small metro areas in measures of socioeconomic well-being that include college attendance, income, and male labor-force participation.

“They can make all the task forces they want, but they’re never gonna stop it because the profits are just too great,” Dennis said. “And the heroin is only getting closer and closer and closer.”

Roughly three-quarters of the dead had started down the same painkiller path that led Jesse to his death, the same path as Spencer Mumpower, Scott Roth, and Colton Banks—with a single prescription pill.

A month after Jesse’s death, the FDA approved a new high-potency, long-acting version of hydrocodone, Zohydro ER, even after its own expert panel voted 11–2 against it, noting that the drug, which lacked an abuse deterrent, could lead to the same level of addiction and abuse as OxyContin had in its original form. The FDA concluded that “the benefits of this product outweigh the risks.” It would be four more years before the FDA would ask a pharmaceutical company to withdraw an opioid pain medication because of its potential for abuse—Opana ER, and not until 2017—and by then the annual death toll for drug overdose had climbed to 64,000.

“The most damaging thing Purdue did, it wasn’t the misbranding of OxyContin they got in trouble for. It was that they made the medical community feel more comfortable with opioids as a class of drugs,” Kolodny told me. “But had the FDA been doing its job properly with regards to opioids, we never would have had this epidemic.”

In the same letter, the FDA denied her secondary request, which was to have the drug limited to severe, acute, or terminal pain—and not prescribed for chronic use unless all other treatments had first been explored, guidelines most other countries in the world have adopted.

Americans, representing 4.4 percent of the world’s population, consume roughly 30 percent of its opioids.

What distinguished Ashlyn as one of the region’s top mules, according to the prosecutor who sent her to prison, wasn’t just the volume of drugs she was transporting; it was also her body’s astonishing ability to metabolize the drug without overdosing. (“Generally speaking, there are people who overdose all the time, then there are people like me who have never overdosed,” she told me.) At the peak of her addiction, Ashlyn was using fifty to sixty bags a day. “She had a remarkable liver,” her prosecutor said.

After the birth of her son, in 2008, she was prescribed Lortab for mastitis, an infection not uncommon among breastfeeding mothers. She had lingering lower-back pain, too—the baby’s head had been resting on her spine throughout her last trimester. When the Lortab ran out, her obstetrician wrote her another script, for oxycodone. Within six weeks of giving birth, Ashlyn said, she was hooked.

She switched to Roxicodone in 2010, when OxyContin became abuse-resistant, then to heroin when the black-market Roxys became more expensive and harder to get. “It’s unreal how many people followed that same pattern: Oxys-Roxys-heroin,” she told me. “If you ask me, OxyContin is the sole reason for all this heroin abuse. If I had the choice between heroin and Oxys, I would choose Oxys.…With pills, you always knew what you were getting.”