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

by Beth Macy

“There’s just something so fundamentally soul-sucking about heroin,”

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.

“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.

“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.”

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

But the largest dealers weren’t twice-convicted felons like Ronnie Jones with elaborate dope-cutting schemes, multiple cars, and hired mules. They were local users, many of them female, dispatched to buy the heroin from a bulk dealer out of state, in exchange for a cut. And they were as elusive as hell to catch.

a plethora of shoddy prescribers in rural Virginia and elsewhere in Appalachia had given the good clinics a bad name. Operating at clinics often located in strip malls and bearing generic-sounding names, some practitioners defy treatment protocols by not drug-testing their patients or mandating counseling, and by co-prescribing Xanax, Klonopin, and other benzodiazepines—the so-called Cadillac high.

It had been that way since the birth of methadone, a synthetic painkiller developed for battlefield injuries that was discovered in—or rather, recovered from—German labs shortly after World War II.

While methadone remained on the fringes of medical respectability for decades, the Nixon administration sought it out as a way to control crime and respond to concerns over the fact that 20 percent of Vietnam veterans (at a rate of fourteen hundred soldiers per month) were returning home addicted to opium or morphine. Doctors weren’t trusted, though, to both dispense the drugs and control for their illicit diversion in an office setting, so highly regulated, stand-alone methadone clinics became the norm.

“We’ve had thirteen babies born to mothers on MAT, and not one of those babies had NAS,” Tazewell County judge Jack Hurley told me. “So tell me: How do you put a price tag on that?”

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.

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 some states, people with drug charges are permanently barred from getting food stamps, a holdover from a 1996 federal ban.

“It makes a huge difference,” Stevenson told me. “If we reduced our prison population by twenty-five percent, that’s twenty billion dollars we could save. And if we invested half of that in treatment, we could really increase people’s likelihood of success.”

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.

Jurisdictions across the country increasingly inhibit ex-offenders’ ability to reenter society by assessing hefty court fines and fees, requiring them to pay thousands or face more jail time.

Purdue had followed Big Tobacco’s playbook when it downplayed the risks of its drug, and now some of America’s best legal minds were trying to make it and other pharmaceutical companies pay for the “public nuisance” burdening their communities.

The optics of the opioid epidemic had clearly been bad for business. While Ronnie turned gray in prison and Kristi prepared the next seasonal decorations for Jesse’s grave, the Sacklers’ rank among “America’s Richest Families” slid from sixteenth to nineteenth on the Forbes list.

The work at the Narcotics Farm labs led to the field of addiction medicine. Both farms closed in the mid-1970s—due to an ethics scandal over experimentation on the addicted who were improperly exploited as research subjects. But their legacy includes the establishment of the National Institute on Drug Abuse and the scientific notion that addiction is a chronic, relapse-ridden disease.

A journalist and former colleague of mine was so worried about the epidemic’s chilling effect on painkillers that she emailed me an X-ray of her back, showing a sixty-four-degree curve in her lumbar spine—from the front, it resembled a question mark—and slipped disks that caused severe arthritis pain. Painkillers had allowed her to work and actively pursue gardening, cooking, and beekeeping, and they precluded risky and potentially debilitating surgery. And yet her scoliosis specialist had recently discontinued her pain management “without any notice and with no discussion during appointments to come up with a pain management strategy” because the new CDC guideline “frightened him into abandoning his patients,” she said. (For her arthritis, she takes the synthetic opioid Tramadol; for neuropathy, she takes the seizure medication gabapentin, which is increasingly sought on the black market for its sedative effects.) “My life is not less important than that of an addict,” my friend wrote, in bold letters, explaining that her new practitioner requires her to submit to pill counts, lower-dose prescriptions, and more frequent visits for refills, which increase her out-of-pocket expense.

To follow the physician’s imperative of “Do no harm” in a landscape dominated by Big Pharma and its marketing priorities, the medical community only recently organized behind renewed efforts to limit opioid prescribing, teach new doctors about the nuances of managing pain, and treat the addicted left in the epidemic’s wake. The number of residency programs in the field of addiction medicine has grown in recent years from a dozen to eighteen.

“You can fix it upstream, when it’s affordable, or you can wait till they present back in the ER with stage-four cancer or cirrhosis, and they still need extended hospital stays,” Tyson said. “It’s a drain on the system no matter what, so why can’t we fix it upstream?”

America’s approach to its opioid problem is to rely on Battle of Dunkirk strategies—leaving the fight to well-meaning citizens, in their fishing vessels and private boats—when what’s really needed to win the war is a full-on Normandy Invasion.

Drug-overdose deaths had doubled every eight years over that time: Three hundred thousand Americans had died of overdose in the past fifteen years, and lacking dramatic interventions, the same number would die in just the next five.

Opioids are now on pace to kill as many Americans in a decade as HIV/AIDS has since it began,

Finding a balance between treating and perpetuating addiction had been pursued in the United States since the 1800s, when doctors used morphine to wean patients from laudanum, then later used heroin to get patients off morphine. Soldier’s disease had sparked a period of stern prohibition in the Harrison Act and, eventually, the War on Drugs. “Our wacky culture can’t seem to do anything in a nuanced way,” explained Dr. Marc Fishman, a Johns Hopkins researcher and MAT provider.

The naysayers would be more open to MAT if its proponents would more openly acknowledge the drawbacks of maintenance drugs—significant relapse rates when patients stop treatment, for instance—instead of portraying them as a kind of perfect chemical fix, Fishman argued.

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