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

by Beth Macy

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.

While more and more Americans die of drug overdose, it is impossible to not look back at the early days of what we now recognize as an epidemic and wonder what might have been done to slow or stop it. Kristi Fernandez’s questions are not hers alone. Until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment.

The informant had more specifics: Users had already figured out an end run around the pill’s time-release mechanism, a coating stamped with OC and the milligram dosage. They simply popped a tablet in their mouths for a minute or two, until the rubberized coating melted away, then rubbed it off on their shirts. Forty-milligram Oxys left an orange sheen on their shirtsleeves, the 80-milligrams a tinge of green. The remaining tiny pearl of pure oxycodone could be crushed, then snorted or mixed with water and injected. The euphoria was immediate and intense, with a purity similar to that of heroin.

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.”

“My fear is that these are sentinel areas, just as San Francisco and New York were in the early years of HIV.”

At a forum for area doctors and families, Van Zee brought in Yale University substance abuse experts to describe the sudden physical and psychological stress caused by dopesickness, outlining a hard truth that many Americans still fail to grasp: 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.

And what this patient wanted Bickel to know was no different than what the Lee County farmer meant when he told his doctor how OxyContin had stolen everything from him: Nothing’s more powerful than the morphine molecule, and once it has its hooks in you, nothing matters more. Not love. Not family. Not sex. Not shelter. The only relationship that matters is between you and the drug.

Stigma was the real enemy of hope for the drug-addicted, Hadden decided. So to tamp it down, she decided her job was to explain the misunderstood science of addiction: Once a person becomes addicted, he loses his power of choice; his free will becomes hijacked along with the opioid receptors in his brain. When a person’s natural opioids are shut down by the deluge of synthetic ones, she told the audience at the community meeting, it creates a growing tolerance to the drug, making the brain crave ever-larger quantities of opioids just to keep from being violently ill.

Consumers all got cheaper jeans, yes, but what did that matter to the people who had once stitched them if they were now out of work and couldn’t afford new clothes? The global economy created winners and losers, Bassett Furniture CEO Rob Spilman told me, explaining the dismissal of some eight thousand furniture workers from his payroll. “It was that or perish,” he said. “At the end of the day, we are not a social experiment.

Drug epidemics unfold “like a vector phenomenon, where you have one individual who seeds that community and then the spread begins,” said Dr. Anna Lembke, an addiction-medicine specialist at the Stanford University School of Medicine and the author of Drug Dealer, MD. People whose parents or grandparents were drug- or alcohol-addicted have dramatically increased odds of becoming addicted themselves, with genetics accounting for 50 to 60 percent of that risk, Lembke explained; she noted that the correlation between family history and depression is much lower, 30 percent. Other risk factors for addiction include poverty, unemployment, multigenerational trauma, and access to drugs.

“If it had been an infectious disease, there would have been widespread panic.”

“As long as it was in the lower economic classes and marginalized groups, like musicians and people of ethnic minorities, it was OK because it was with those people,” said Spencer’s counselor, Vinnie Dabney, an African American who took his first sniff from a bag of heroin his sophomore year of high school, in 1968, and was a mostly functional user for thirty years. (Needle-phobic, he never once shot up.) Back then you could maintain that way because the drug’s potency was low—3 to 7 percent, compared with 40 to 60 percent today—and the police paid little attention, since white kids in the suburbs weren’t dying or nodding out in the football bleachers.

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

Lembke pins the opioid epidemic not just on physician overprescribing fueled by Big Pharma but also on the broader American narrative that promotes all pills as a quick fix. Between 1998 and 2005, the abuse of prescription drugs increased a staggering 76 percent.

was like shooting Jesus up in your arm,” Brian said of his first IV injection. “It’s like this white explosion of light in your head. You’re floating on a cloud. You don’t yet know that the first time is the best. After that, you’re just chasing that first high.”

He was weaned off Suboxone after three weeks, a not-uncommon practice that would become increasingly controversial as the treatment became more prominent. 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.”

NIDA, the Institute of Medicine, the World Health Organization, and the White House drug czar’s office would all agree that indefinite (and maybe even lifelong) maintenance treatment is superior to abstinence-based rehab for opioid-use disorder. And even Hazelden, the Betty Ford–affiliated center that originated the concept of the twenty-eight-day rehab, changed its stance on medication-assisted treatment, or MAT, offering Suboxone to some patients in 2012.

“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.

The idea that her son was shooting up heroin hadn’t crossed her mind, she said, then corrected herself: The truth was, the thought had crossed her mind; she just hadn’t let it roost. Despite evidence to the contrary. Despite having already padlocked her bedroom door, to keep Jesse from stealing money for drugs.

Denial; cognitive dissonance

With the legalization of marijuana in a growing number of states, drug cartels were champing at the bit to meet the demand for heroin, a market they needed to grow. “They were looking at a thirty to forty percent reduction in profits because of legalization,” explained Joe Crowder, a Virginia state police special agent and part of the federally funded High Intensity Drug Trafficking Area program that designated Roanoke a heroin hot spot in 2014. “Between the pill epidemic and the less liberal prescribing of pain meds, cartel leaders said, ‘Guess what’s purer, cheaper, and we can make it all day long?’”

Janine could draw a detailed mental map of the flaws in the treatment landscape, from health care privacy hurdles and other treatment barriers to the lack of guidance about what to do the moment you realize your twenty-one-year-old is injecting heroin: Janine had found a box of hypodermic needles hidden in a box in the back of Bobby’s closet.

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.’

Among public health officials, buprenorphine is considered the gold standard for opioid-use disorder because it reduces the risk of overdose death by half compared with behavioral therapy alone. It also helps addicts get their lives together before they very slowly taper off—if they do. 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.

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.”

John’s dad, a retired law enforcement officer, told Janine he’d given many tough-love lectures to parents on the job, but when it came to his own son he was helpless, even denying that the constellation of scars on his son’s arms were track marks.

Public health officials in Vancouver were miles ahead of most of America in so-called harm reduction, a social justice movement aimed at reducing the negative consequences of drug use—without necessarily ending the use—and, more broadly, treating users with dignity and respect. The basic theory being: Users can’t get sober if they’re dead, and it’s cheaper and more humane to give them clean syringes, say, than it is to pay for HIV and/or hepatitis C treatment. Vancouver officials launched supervised injection sites where nurses stood by to revive overdosed users, fostered the free exchange of used needles for clean ones, and distributed naloxone. Sites in Toronto and Ottawa were also approved.

The latest research on substance use disorder from Harvard Medical School shows it takes the typical opioid-addicted user eight years—and four to five treatment attempts—to achieve remission for just a single year. And yet only about 10 percent of the addicted population manages to get access to care and treatment for a disease that has roughly the same incidence rate as diabetes.

When I offered that I was leaving his office after our third interview depressed—again—he said, “Well, you should be. Rehab is a lie. It’s a multibillion-dollar lie.” An annual $35 billion lie—according to a New York Times exposé of a recovery industry it found to be unevenly regulated, rapacious, and largely abstinence-focused when multiple studies show outpatient MAT is the best way to prevent overdose deaths. “I’m afraid we don’t have good data on outcomes from residential programs,” said John Kelly, the Harvard researcher. While research supports users remaining in their home environments on outpatient MAT, desperate families continue to grasp for “cures” offered by companies marketing abstinence-only rehabs. “Part of it is, when you spend that much money, you think it’s going to work,” Cheri Hartman said. “But it is killing people for that myth to be out there—that the only true cure is abstinence.”

Why had blacks failed to become ensnared in opioid addiction? That question was addressed in 2014 data issued by the Centers for Disease Control and Prevention: Doctors didn’t trust people of color not to abuse opioids, so they prescribed them painkillers at far lower rates than they did whites. “It’s a case where racial stereotyping actually seems to be having a protective effect,” marveled researcher Dr. Andrew Kolodny of Brandeis University. Put another way: By 2014, while young whites were dying of overdose at a rate three times higher than they did in 2002, the death rate for people of color was relatively unchanged.

In the 1970s, America decided to deal with drug addiction and dependence as a crime problem rather than a health problem, “because it was popular to find a new community of people to criminalize,” Stevenson explained. “And everybody was preaching the politics of fear and anger.”

As that narrative of addicts as criminals further embedded itself into the national psyche, the public became indifferent to an alternative response that could have eased treatment barriers, he said. As an example he cited Portugal, which decriminalized all drugs, including cocaine and heroin, in 2001, adding housing, food, and job assistance—and now has the lowest drug-use rate in the European Union, along with significantly lowered rates of drug-related HIV and overdose deaths. In Portugal, the resources that were once devoted to prosecuting and imprisoning drug addicts were funneled into treatment instead.

But there weren’t enough pain specialists, and the doctors were increasingly aware of studies showing that long-term opioids in fact created more pain in many patients, a condition known as opioid-induced hyperalgesia.

Today, courts largely continue to send the addicted to prisons when reliable treatment is difficult to secure, and many drug courts controlled by elected prosecutors still refuse to allow MAT, even though every significant scientific study supports its use.

Not every patient wants or needs maintenance drugs, because every human experiences addiction differently, and what works for one might not work for another. Still, it is crucial to preserve treatments for people with addiction and help them obtain the means needed to get off drugs, rather than simply treat them as criminals who have no right to health care.

If my own child were turning tricks on the streets, enslaved not only by the drug but also criminal dealers and pimps, I would want her to have the benefit of maintenance drugs, even if she sometimes misused them or otherwise figured out how to glean a subtle high from the experience. If my child’s fear of dopesickness was so outsized that she refused even MAT, I would want her to have access to clean...

“Perhaps the day will come when more sensible views prevail—that relapse is the norm; that drug addiction should be treated as a chronic, relapsing problem that affects the public health; and that meeting people’s basic needs will dampen their enthusiasm for drugs.” But there is so much more work to be done.

In the carefully couched words of an academic, Burke suggested that the War on Drugs should be overhauled, with input gathered from other countries, including Portugal, that have decriminalized drugs and diverted public monies from incarceration to treatment and job creation.

While Fishman believed buprenorphine, methadone, and naltrexone were all imperfect solutions, they remain, scientifically speaking, the best death-prevention tools in the box.

The local schools had recently adopted new prevention models, after studies showed kids were more likely to use drugs after DARE.

“The more we talk about the epidemic as an individual disease phenomenon or a moral failing, the easier it is to obfuscate and ignore the social and economic conditions that predispose certain individuals to addiction,” Avruch said.

Only one in ten addicted Americans gets any treatment at all for his or her substance use disorder—which is why there’s such a push for outpatient MAT and, increasingly, programs that divert the addicted from jail to treatment.

Loyd believes that all people in recovery, especially those who relapse, should be allowed MAT, even if they have to sue to get it. “The judges who don’t allow it are in violation of the Americans with Disabilities Act. They just are!” he said. Denying opioid-addicted participants medicine they have legitimately been prescribed is akin to denying diabetics their insulin on the grounds that they’re fat.

When I told Bickel that Tess was still living homeless on the streets of Las Vegas, paying for illicit drugs with sex work, he called up a study he’d coauthored in 1988, showing that buprenorphine definitively protects the addicted from overdose death and leads to reduced crime and better health. “Holy mackerel, this is such an old study, but people still aren’t aware,” he said.