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

by Beth Macy

She pointed out news articles I’d missed about people she’d once used drugs with, including a young mother named April who’d recently overdosed in the parking lot of a Roanoke Dollar General store, with her infant found crying in the car seat.

“I now know that he enlisted me because I am a well-spoken, young white girl that drives a nice car, therefore it didn’t look [to police] like we were there for what we were really there for,” she wrote. More important, her craving for the drug was so insatiable—her skinny, desperate look practically screamed white female addict—that no Newark dealer would mistake her for an undercover cop.

Ashlyn realized there was no story to tell herself that didn’t begin with the first of the Twelve Steps, she told me: She was powerless to overcome her addiction. She was about to lose her son, who was six at the time, because she had chosen heroin over him.

On what he thinks of law enforcement’s efforts to quell the opioid epidemic: Not much. The system is too rigidified, as Garfield would say, not nimble enough to combat heroin’s exponential growth. The drug’s too addictive, the money too good. “You whack one [dealer], and the others just pop right up, like Whac-A-Mole,” Bassford said.

“We’ll score a huge drug bust that we’ve been working on for maybe a year, and all that does is create a vacuum in the market that lasts maybe five to seven days,” said Isaac Van Patten, a Radford University criminologist and data analyst for Roanoke city police. “And because the amounts of money involved are so vast, we’re not going to stamp it out.

“In the suburbs, heroin started out as a trendy drug that people believed they could control. But the rich kids spiraled right down with everybody else and then, suddenly, you couldn’t tell between the two.”

Fifteen years earlier, Art Van Zee had predicted that OxyContin would eventually be recalled—but not until rich kids in the suburbs were dying from it. Now they were, and that pained him equally, he told me. “I was absolutely dead wrong.”

Tess knew only that her daily compulsion for opioids began in 2012, the same way four out of five heroin addicts come to the drugs: through prescribed opioids.

The so-called upscheduling had been controversial, with public opinion weighing in pro (52 percent) and con (41). Chronic-pain patients complained loudly about the added cost and inconvenience. “Just because the DEA cannot figure out how to control the illegal use of these drugs should not be a reason to penalize millions of responsible individuals in serious pain,” one critic wrote in a published letter to pharmacist Joe Graedon, The People’s Pharmacy columnist. On a website set up by the DEA for public feedback, several patients warned that rescheduling the drugs would limit their availability and drive people to street drugs—particularly heroin.

“Not to sound racist or anything, but typically black opiate dealers do not use heroin. Good dealers don’t use what they sell because they know they would just use it all,” she said.

Some dealers encouraged underlings to “hot pack” their product, giving superhigh potencies to new users to hook them quicker. Once the user is hooked, the product gets titrated back, forcing the person to buy more.

Tess said she didn’t consider herself a true addict until six months after she started snorting heroin, when she began injecting it. After three shots, though, she knew she’d never return to snorting.

“I worked just to use, and I used just so I could work,” Tess explained. “There was no in between.”

No matter how low Tess got, it seemed there was always a deeper and fresher hell awaiting her.

Inside the cup was a low dose of Tylenol with the opioid codeine. It was designed to keep the fetus growing inside Tess from going into sudden, potentially fatal opioid withdrawal. Twenty-five and five foot seven, Tess was down to 120 pounds. She hadn’t had a regular period in two years. She had no idea she was at the end of her second trimester of pregnancy. At least in jail, for the immediate future, she and the baby were safe.

The culprit was fentanyl, once a popularly diverted opioid prescribed in patch form for advanced-cancer patients that was now being illicitly imported from China and mixed with heroin or manufactured into pills.

News that people were dying from fentanyl-laced heroin didn’t intimidate heroin addicts, according to several I interviewed. On the contrary, the lure of an even stronger high drew them to it more.

He remembers finding a pair of Radford University coeds at one bust, naked on a couch in a Roanoke drug house, enveloped in a heroin fog. They’d exchanged sex for the drug, injecting it between their toes so their friends and professors wouldn’t know. Stunned, Perkins remembers calling their parents in the Washington suburbs and saying, “I can’t tell you this over the phone. You just need to come.”

“The market is so saturated, I can’t say it enough: There is so much heroin out there,” sold not only by former crack dealers eager to diversify their product but also by subordinates, or subdealers, Perkins said. So much that Roanoke police seized 560 grams of the stuff in 2015 alone—the equivalent of 18,666 doses or shots.

“She’s next on the list” to be admitted, a rehab intake counselor texted Jamie the next day. But it was too late. “She died in a motel last night,” Jamie wrote back.

What Janine did was sob. “It was the worst moment in my life. I didn’t understand yet the connection between pills and heroin. I kept thinking, ‘He’s gonna get better; it’s just pills.’ “I’m in health care, and there were just so many things I didn’t know,” she said. “It’s almost impossible the way the systems are set up, for a parent to get good treatment for their child.”

In states where Medicaid expansions were passed, the safety-net program had become the most important epidemic-fighting tool, paying for treatment, counseling, and addiction medications, and filling other long-standing gaps in care. It gave coverage to an additional 1.3 million addicted users who were not poor enough for Medicaid but too poor for private insurance.

Perkins hated political maneuvering. In his ideal world, the economics of securing help worked like this: Since addicts would be diverted from jail, the cost savings from their empty jail beds could be put toward treatment. “The problem is, it’s easier to give money to the corrections system—to the tune of one billion in the state of Virginia—than it is to take a couple of million dollars and provide inpatient treatment for our problem,” he railed, blaming politics and the tendency among jailers and sheriff’s departments to cling to bloated incarceration budgets championed during the War on Drugs, even though two hundred of the city jail’s eight hundred beds were typically empty.

Perkins pointed out that most addicted users return to the streets from jail with more drug contacts than they had when they arrived. “I said it all a thousand times, but I couldn’t get anybody to listen because the sheriffs are elected officials with powerful lobbyists, and a poor old appointed police chief doesn’t stand a chance,” he said.

In fact, HIV, spurred by the sharing of dirty heroin needles, was on the rise again, with sixty-five new cases reported that year in rural southwestern Virginia alone.

“My fear is that these are sentinel areas, just as San Francisco and New York were in the early years of HIV,” he had written of Lee County back in November 2000. Van Zee had no idea then that the OxyContin epidemic would become a heroin epidemic, which itself would lead to more deaths from HIV and hepatitis C.

From a distance of almost two decades, it was easier now to see that we had invited into our country our own demise.

An NAS baby is a portrait of dopesickness in miniature: Their limbs are typically clenched, as if in agony, their cries high-pitched and inconsolable. They have a hard time latching on to either breast or bottle, and many suffer from diarrhea and vomiting.

He was not among the children seen at the region’s NAS clinic, where dependent babies released from the NICU come back for weekly check-ins while being very slowly weaned from methadone under their mother’s or another family member’s watch; despite such attention, around 27 percent of the clinic babies end up in foster care.

“These moms are so over the top after they deliver because they’re trying to show everybody how much they care,” Kim Ramsey, the hospital’s neonatology nurse specialist, explained. Many have been stigmatized by their friends and families, even by members of the hospital staff.

“Our staff used to be really ugly to them,” Ramsey admitted. “They’d say, ‘This is ridiculous. These moms need to quit having babies and quit doing drugs,’ myself included. We had no understanding that these women’s brains have been altered, and what they need now more than anything, for the sake of the baby, is our support.”

“It’s a real racket,” Tess’s mom, Patricia, said of cash-only MAT practices. “And there are waiting lists just to get into most of these places.”

“When calling facilities there is rarely a sense of urgency for capturing the addict,” Patricia explained, in the middle of a subsequent crisis with Tess. “An application process has to be completed. How many addicts on the streets have insurance, Medicaid, or ability to fax lengthy applications, or access to large amounts of cash?”

For now, Tess and her mom had to pay cash, up front, at every visit.

One researcher recommended that MAT users stay on maintenance drugs at least twice as long as the length of their addiction, while others believe it’s too risky for long-term addicts to ever come off the drugs.

Overprescribing among doctors specializing in addiction treatment was rampant, according to several rural MAT patients I talked to who unpacked how Suboxone doctors prescribed them twice as much of the drug as they needed, fully knowing they would sell some on the black market so they could afford to return for the next visit. Others traded their prescribed Suboxone for illicit heroin or pills.

God help us

“We have people shooting up Suboxone and abusing it every which way,” Mark Mitchell, the Lebanon police chief, told me. “For a town of just thirty-four hundred to have three Suboxone clinics—that’s absurd.”

Suboxone, with its blocking agent naloxone, “is a wonderful medicine, but we were seeing actual deaths from Subutex here, where people are injecting very high doses of it. And it comes down to these physicians wanting to make so much money, just like they did with the opioid pills!”

In Johnson City, Tennessee, just over the Virginia border—where several of the nation’s top buprenorphine prescribers have offices—one cash-only prescriber admitted as much in a public forum, saying, “We give ’em enough so they can sell it and stay in treatment,” Melton recalled. Buprenorphine is the third-most-diverted opioid in the country, after oxycodone and hydrocodone.

By the time I met Tess, she had just returned home and was hoping to transfer to a sober-living or halfway house—but the problem was, many didn’t allow MAT, and none of the available facilities would allow her to bring the baby. So she was back at her mom’s house and on MAT.

Tess’s problems were growing worse by the minute, and the systems designed to address them were lagging further behind, mired in bureaucratic indifference.

If you were drawing a Venn diagram comparing Suboxone attitudes among public health experts and criminal justice officials in the Appalachian Bible Belt communities where the painkiller epidemic initially took root, the spheres would just barely touch.

As early as 1963, progressive researchers conceded that designing the perfect cure for addiction wasn’t scientifically possible, and that maintenance drugs would not “solve the addiction problem overnight,” considering the trenchant complexities of international drug trafficking and the psychosocial pain that for millennia has prompted many humans to crave the relief of drugs.

When complicated lives need repair, and even the best-intentioned doctors are rushed, it was as clear then as it is now: Medication can only do so much.

But as liberally as doctors could prescribe opioid painkillers up through 2016, they remained regulated as hell when it came to treating opioid addiction with methadone and buprenorphine—the latter of which only came to market in 2002, after a thirty-year quest for a new addiction-treatment drug.

Most of the country’s three thousand drug courts drop the charges when offenders complete the twelve- to eighteen-month program. Graduates are roughly a half to a third less likely to return to crime or drugs than regular probationers. Drug courts remain, then, an almost singular place where prosecutors, defense attorneys, judges, and mental health advocates gather around a table to coordinate care and punishment, and discuss the daily challenges of the addicted.

“The best research says counseling doesn’t help: ‘Just give ’em the pill. Give ’em the fucking pill,’” said a local addiction counselor, Anne Giles, who was furious about cultural biases against MAT.

According to an analysis of international studies published in the Lancet, the best treatment for opioid addiction combines MAT with psychosocial support, “although some benefit is seen even with low dose and minimum support.”

Don Flattery, a member of the Virginia Governor’s Task Force on Prescription Drug and Heroin Abuse, compared anti-MAT judges and police officers to climate-change deniers. He’d lost his twenty-six-year-old son, Kevin, to an opioid overdose and tortured himself for not insisting that Kevin stick with MAT. His son had been on Suboxone before but abandoned it prematurely, after feeling stigmatized for it, in favor of abstinence-only treatment, Flattery said.

To fix the problem, public policy makers should, in Van Zee’s opinion, incentivize more doctors to go into addiction medicine, and MAT should be predominantly expanded in the nonprofit realm of health departments, community service boards, and federally qualified health centers, where salaried doctors are less motivated to overprescribe.