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

by Beth Macy

For the fifth year in a row, the state of West Virginia’s indigent burial-assistance program was about to exhaust its funds from interring opioid-overdose victims.

Drug overdose had already taken the lives of 300,000 Americans over the past fifteen years, and experts now predicted that 300,000 more would die in only the next five. 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.

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.

Until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment.

Because the most important thing for the morphine-hijacked brain is, always, not to experience the crushing physical and psychological pain of withdrawal: to avoid dopesickness at any cost.

Up the Shenandoah Valley on the interstate, I pass New Market and think not of the men who fought in the famous 1864 Civil War battle but of the women who grew poppies for the benefit of wounded soldiers, harvesting morphine from the dried juice inside the seed pods. Three decades later, the German elixir peddlers at Bayer Laboratories would stock America’s drugstores with a brand-new version of that same molecule, a pill marketed as both a cough remedy and a cure for the nation’s soaring morphine epidemic, known as “morphinism,” or soldier’s disease. Its label looked like an amusement advertisement you might have seen on a circus poster, a word derived from the German for “heroic” and bracketed by a swirling ribbon frame: heroin. It was sold widely from drugstore counters, no prescription necessary, not only for veterans but also for women with menstrual cramps and babies with hiccups.

In the 1820s, one of Boston’s leading merchants masterminded an opium-smuggling operation off the Cantonese coast, spawning millions for Boston Brahmins with the names of Cabot, Delano (as in FDR), and Forbes. This money would go on to build many of the nation’s first railroads, mines, and factories.

“I consider it my duty to attract attention to the terrible effects of this new substance in order that calamity may be averted,” Sertürner wrote, prophetically, in 1810.

Dr. Alexander Wood, the Scottish inventor of the hypodermic needle, hailed his 1853 creation by swearing that, whereas smoking or swallowing morphine caused addiction, shooting it up would not.

At the dawn of the twentieth century, the pendulum began to swing the other way as a few prominent doctors started to call out their overprescribing peers.

And yet heroin’s earliest years were mostly full of praise, as medical journals heralded Bayer’s new cough suppressant, considering it distinctly superior to and apart from morphine, some promoting it as a morphine-replacement drug. Though a few researchers warned about possible addiction—“the toxic properties of the drug are not thoroughly known,” one noted in 1900—for eight years you could buy heroin at any American drugstore or by mail order.

In 1906, the American Medical Association finally sounded a sterner alarm:

The addicted were now termed “junkies,” inner-city users who supported their habit by collecting and selling scrap metal. The “respectable” upper- and middle-class opium and morphine addicts having died out, the remaining addicted were reclassified as criminals, not patients.

But the yellowed newspaper warnings would become moot, like so many historical footnotes—destined to repeat themselves as soon as they receded from living memory.

No one saw the train wreck coming—not the epidemiologists, not the criminologists, not even the scholars who for decades had dissected the historical arc of Papaver somniferum, the opium poppy.

The 1996 introduction of OxyContin coincided with the moment in medical history when doctors, hospitals, and accreditation boards were adopting the notion of pain as “the fifth vital sign,” developing new standards for pain assessment and treatment that gave pain equal status with blood pressure, heart rate, respiratory rate, and temperature.

The seismic shift toward thinking of patients as health care consumers was already under way, as patients now rated their health care experiences in formal surveys, Press Ganey the largest among them, 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.

Throughout OxyContin’s earliest years, only a few voices of dissent rose to remind doctors that, historically, there had been risks associated with prescribing narcotics, and even those warnings were timid.

The first real dissent would come soon, though, in the unlikely form of a country doctor and one thoroughly pissed-off Catholic-nun-turned-drug counselor. Though Dr. Art Van Zee and his colleague Sister Beth Davies would sound the epidemic’s first sentinel alarm from Appalachia, they were greeted with the same indifference as the Richmond doctor who demanded prompt action to curb the rampant use of opioids in 1884, and the inventor of morphine, who strongly urged caution in 1810. Their outsider status disguised both the depth and the relevance of their knowledge.

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

She was told it was a problem for the Department of Behavioral Health and Substance Abuse Health Services. Even though the infections put people at risk of tuberculosis, and the shared needles (and snorting straws) could hasten the spread of hepatitis C and HIV, the buck was passed. Officially, this was not a public health matter.

In 1997, the Roanoke-based medical examiner counted one OxyContin death in southwest Virginia, the next year three, and the year after that sixteen. But those numbers were inexplicably unexposed until 2001, five years after Purdue launched its drug. A Drug Enforcement Administration official told a Richmond reporter that illicit opioids were unlikely to spread beyond the mountains to the state capital, declaring southwest Virginia “a little bit unique,” although he conceded there were other Oxy-abuse hot spots in rural Maine, Cincinnati, Baltimore, and Charleston, West Virginia.

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

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.

A year after starring in the Purdue Pharma video, that same doctor, South Carolina pain specialist Dr. Alan Spanos, gave a lecture insisting that patients with chronic noncancer pain should be trusted to decide for themselves how many painkillers they could take without overdosing—just as the morphine-dispensing doctors had said of wounded Civil War veterans a century before. He reasoned that the patients would simply “go to sleep” before they stopped breathing.

The next month, the DEA developed a “national action plan” to monitor Purdue, asking the company to limit distribution of the drug, rethink its marketing strategy, and consider reformulating the drug to be abuse-resistant. 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.

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.

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.”

“They’re saying it’s nonaddictive, but you mark my words: This is the beginning of a disaster for us.”

Even if Big Pharma and the pill-mill doctors could be brought to justice, the morphine molecule was so deadly, its lure so intractable, that those who were already addicted were likely to be ruled by it for the rest of their lives.

The first time Ed Bisch heard the word “OxyContin,” his son was dead from it. If parents were slow to catch on to the epidemic, experts weren’t any quicker. The movement of OxyContin from the economically straitened hinterlands to the largely more affluent cities and suburbs in the early aughts reminded historian David Courtwright of the iatrogenic wave of opium and morphine addiction that stormed the nation exactly a century before. 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. The hipster counterculture took inspiration from heroin-addicted jazz greats like Charlie Parker and John Coltrane.

“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. For centuries, dealers of opium, morphine, and heroin understood that an addicted person’s fear of running out—of becoming dopesick—portended one hell of a business model.

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). It was Ed Bisch’s message board sprung to life, a nonvirtual resistance party that would play out politically and in person over the next decade.

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.

A similar FDA petition to force Purdue to put stronger warning labels on OxyContin, detailing the risks of frequent prescribing, had been filed by the Connecticut attorney general in 2004—and was stalled in bureaucratic purgatory. (That initial application would be rejected four years later, in 2008.)

The terrorist attacks had elevated Giuliani’s stature, but in a boon moment for his future employer, they also temporarily diverted media attention from OxyContin. A sales executive said as much to Purdue employees on September 12, via voicemail, giving them the day off. The message the sales manager left, according to a former Purdue staffer: At least the tragedy for the nation would take OxyContin off the front pages of the nation’s newspapers.

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

In the fall of 2006, Purdue’s lawyers began to sense that this case against them was different; that a full-court press meant nothing when the opposing counsel was the United States of America. Was it really possible the small-town lawyers had compiled enough evidence to indict both the company and its top executives on a host of felony charges, not just for misbranding the drug but also for mail fraud, wire fraud, and money laundering? It seemed so, according to a memo written by the federal prosecutors to Brownlee at the time.

Rather than risk more serious charges or a jury trial in western Virginia, where the drug’s problems were by now legend, the company accepted the plea agreement later that night. But Purdue wasn’t quite finished negotiating. Eight days after it accepted the deal, Brownlee was stunned to see his name on a firing list, along with four other U.S. attorneys. Though he wasn’t ultimately fired, the incident provided fresh criticism of then–attorney general Alberto Gonzales, accused of trying to sway the work of U.S. attorneys’ offices.

To resolve the federal criminal and civil misbranding charges, Purdue would pay $600 million in fines and admit that for six years it had fraudulently marketed OxyContin as being less prone to abuse and having fewer narcotic side effects than instant-release versions of the drug—a felony misbranding charge. Top executives Paul Goldenheim, Michael Friedman, and Udell would pony up $34.5 million (or, rather, the firm would, on their behalf) and plead guilty to misdemeanor versions of the crime. The fines against Purdue and its executives accounted for about 90 percent of the company’s profits from the time the drug went on the market, in 1996, until 2001, when Purdue dropped the insert language about the timed-lapse mechanism’s ability to “reduce the abuse liability of a drug,” Brownlee explained. It was the eleventh-largest fine paid by a pharmaceutical firm in the Justice Department’s history.

At the time of his death, in 1987, Arthur was lionized for his entrepreneurial vision and boundless obsession for collecting things. Especially art. He once talked the Met into letting him reimburse the museum for four major works that the museum already owned just so he could have them displayed with his name as the donor.

“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.”

Many anti-opioid activists were mad, too, that technically it was Purdue Frederick, Purdue Pharma’s holding company, that was banned from participating in the federal insurance programs Medicaid, Medicare, and Tricare as part of its five-year probation—rather than Purdue Pharma itself, which was still permitted to participate, and therefore to continue selling OxyContin.

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,

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.

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.” And the helicopters were nowhere in sight.

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.