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

by Beth Macy

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.

If fat was the new skinny, pills were becoming the new coal.

The “respectable” upper- and middle-class opium and morphine addicts having died out, the remaining addicted were reclassified as criminals, not patients.

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.

Purdue handpicked the physicians who were most susceptible to their marketing, using information it bought from a data-mining network, IMS Health, to determine which doctors in which towns prescribed the most competing painkillers.

Van Zee sounded the alarm about OxyContin just as its makers were on the threshold of grossing its first billion on the blockbuster drug.

“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.

This marked the first time in the agency’s history that it targeted a specific drug to be policed by its manufacturer to prevent diversion and abuse.

The Purdue offer was just another page in an old story.

The first time Ed Bisch heard the word “OxyContin,” his son was dead from it.

“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.

He told Katz he’d spent months looking for studies that addressed the long-term-abuse risks to patients who used painkillers. “There’s a reason you didn’t find any,” Katz, also a prominent pain doctor, explained. “They don’t exist.”

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,

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.

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

“But you can’t put a corporation in jail; you just take their money, and it’s not really their money anyway. “The corporation feels no pain.”

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.

Spencer’s master class in drug abuse had gone unheeded, boxed away into a category of Things That Happen to Other Families.

Between 1991 and 2010, the number of prescribed stimulants increased tenfold among all ages, with prescriptions for attention-deficit-disorder drugs tripling among school-age children between 1990 and 1995 alone. “And we’re prescribing to ever- and ever-younger children, some kids as young as two years old,” said Lembke, the addiction researcher. “It’s just nuts. Because if we really believe that addiction is a result of changes in the brain due to chronic heavy drug exposure, how can we believe that stimulant exposure isn’t going to change these kids’ brains in a way that makes them more vulnerable to harder drugs?” she added.

Fewer than one-quarter of heroin addicts who receive abstinence-only counseling and support remain clean two or more years. The recovery rate is higher, roughly 40 to 60 percent, among those who get counseling, support group, and medication-assisted treatment such as methadone, buprenorphine, or naltrexone.

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.

“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.”

she said, after reading a New Yorker piece on the Sackler brothers, it dawned on her that the reformulation had almost certainly been prompted by the fact that Purdue was losing its patent on the original formulation, “not because they believed the reformulated version was safer, nor because of my petition.”

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

“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. But Frederick Douglass had it right when he said, “Power concedes nothing without a demand.”

It wasn’t just the money and limited treatment capacity that waylaid people; it was the morphine-hijacked brain, the scrambled neurotransmitters that kept people from thinking clearly or regulating their pain with nonnarcotic substances, or imagining the possibility of feeling happy again.

“I promised myself I’d never grow up to be like my father, and while I may not have an addiction to an actual drug, I do feel my addiction,” he said. “I’m addicted to that lifestyle. It wasn’t my intention. I didn’t want to do it. But no one would give me a job in the field I’d trained for, and no one would let me create my own.”

“We live in an era where for a century now the pharmaceutical industry has invested enormous capital investments in new drugs, and there’s no turning back that clock,” said Caroline Jean Acker, an addiction historian. “So, as a society, we’re going to have to learn to live with possibly dangerous or at least risky new drugs—because Big Pharma’s going to keep churning them out.”

“We are pioneers when it comes to this drug epidemic. We can tell people what will happen in their other communities in twenty years because it’s already happened here to us. We are the canaries in the coalfields.”

Van Zee told me his greatest fear now was of being hit by an intoxicated driver while he jogged the winding roads—not because he feared his own death but because where, then, would his patients go?

The fix isn’t more Suboxone or lectures on morality but rather a reinvigorated democracy that provides a pathway for meaningful work, with a living wage, for everybody.