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

by Beth Macy

illuminate the need for patients not only to become more discerning consumers of health care but also to employ a healthy skepticism the next time a pharmaceutical company announces its latest wonder drug.

I thought of the “tsunami of misery” Jones had first unleashed in Woodstock, Virginia, as his prosecutor put it, before it fanned out in waves over the northwestern region of the state and into some of Washington’s western bedroom communities in 2012 and 2013. In just a few months’ time, Jones was presiding over the largest heroin ring in the region, transforming a handful of users into hundreds.

Carfentanil is an elephant sedative one hundred times stronger than fentanyl, which is twenty-five to fifty times stronger than heroin.

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.

Ronnie Jones had run one of the largest drug rings in the mid-Atlantic United States, a region with some of the highest overdose rates in the nation.

Dopesick begins in the coalfields, in the hamlet of St. Charles, Virginia, in the remote westernmost corner of the state, largely with the introduction of the painkiller OxyContin in 1996.

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.

But in Appalachia, those disparities are even starker, with overdose mortality rates 65 percent higher than in the rest of the nation.

In 1804, at the end of Alexander Hamilton’s ill-fated duel, doctors gave him laudanum to numb the agony caused by the bullet that pierced his liver, then lodged in his vertebrae.

Diacetylmorphine—aka heroin—was more than twice as powerful as morphine, which was already ten times stronger than opium.

The Harrison Narcotics Act of 1914 severely restricted the sale and possession of heroin and other narcotic drugs, and by 1924 the manufacture of heroin was outlawed, twenty-six years after Bayer’s pill came to market.

The addicted were now termed “junkies,” inner-city users who supported their habit by collecting and selling scrap metal.

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.

experts would later concede that it was objective only in appearance—transition labor and a stubbed toe could both measure as a ten, depending on a person’s tolerance.

The advent of the pain score, we now think, got patients used to the idea that zero pain was the goal,

Little did Davis or the other ER docs understand that the routine practice of sending patients home with a two-week supply of oxycodone or hydrocodone would culminate by the year 2017 in a financial toll of $1 trillion as measured in lost productivity and increased health care, social services, education, and law enforcement costs.

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.

She recalled the first phone call she’d taken about the drug, in the late 1990s. The informant had told the cop. The cop called the pharmacist. The pharmacist called Sister Beth.

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.

To help burnish its image in the face of so many legal, financial, and public-relations problems, Purdue hired former New York mayor and Republican insider Rudy Giuliani and his consulting firm, Giuliani Partners. Just a few months after his lauded response to the 9/11 terrorist attacks, Giuliani’s job was to convince “public officials they could trust Purdue because they could trust him,” as Barry Meier and another writer at the New York Times put it.

Purdue Pharma heaped praise on its American hero and new political star: “We believe that government officials are more comfortable knowing that Giuliani is advising Purdue Pharma,”

To lead the Purdue investigation, he appointed assistant U.S. attorneys Randy Ramseyer and Rick Mountcastle, career government lawyers who were not given to drama and worked three hours west of Brownlee in the district’s satellite office in Abingdon, closer to the coalfields.

Unlike the civil lawsuits that preceded them, Brownlee’s team had to prove only that the company had “misbranded” the drug, a broad and somewhat technical charge that makes it a crime to mislabel a drug or fraudulently promote it, or market it for an unapproved use.

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.

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.

the novelist Barbara Kingsolver was about to launch a trendy farm-to-table restaurant, the Harvest Table, in nearby Meadowview,

enough opioid painkillers had been prescribed in 2010 to medicate every American adult around the clock for a month.

according to the rep-call notes subpoenaed for the case, OxyContin and Senokot were routinely recommended hand in hand. “So they got you on both ends!” Ramseyer said.

Roanoke is a smallish city, transformed in the mid-1880s into a gritty railroad town and now, more than a century later, striving to become a health care, neuroscience, and medical-research hub.

the legal and medical structures meant to combat America’s heroin epidemic were woefully disconnected, often at odds with one another, and full of unintended consequences.

the federal disability program was becoming a de facto safety net for the formerly employed, a well-intentioned but ultimately disastrous way of incentivizing poor people to stay sick, with mental illness and chronic pain—conditions that are hard to prove and frequently associated with mental health and substance use disorders—prompting the majority of disability awards.

That same pattern was playing out in the Lee County coalfields, where some parents coaxed their children’s doctors toward ADHD diagnoses, knowing that such behavioral problems could help make them eligible for Social Security disability when they became adults. “Ritalin is a pipeline to disability here,”

The federal government spent an estimated $192 billion on disability payments in 2017 alone, more than the combined total for food stamps, welfare, housing subsidies, and unemployment assistance.

Those of us living highly curated and time-strapped lives in cities across America—predominantly mixing virtually and physically with people whose views echoed our own—had no idea how politically and economically splintered our nation had become. And also how much poorer and sicker and work-starved the already struggling parts of the nation truly were—because we didn’t follow that story.

We may feel more connected by our cellphones and computers, but in reality we are more divided than ever before.

We were safe in our ignorance, or so we thought—content to stereotype drug addiction as the affliction of jobless hillbillies, a small group of inner-city blacks, and a few misguided suburban kids.

“Crystal meth controls all the dockets now” in rural Virginia, a local drug task force officer told me. “If you’re addicted to painkillers, you become so lethargic you can hardly function. But meth keeps you going if you need to run the streets to go get your next dose of heroin or pills, to keep you from getting sick. It allows you to function. There’s a reason they call it ‘high-speed chicken feed.’”

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.

“The issue is Interstate 81,” Wunsch told me. “The OxyContin epidemic spread from East Nowhere Jesus all up and down the Appalachian chain by way of the interstate, and suddenly my own kids were coming home from parties,” talking about pills being passed around in bowls.

One of the most segregated cities in the South, Roanoke had long had a steady but largely quiet group of heroin users in its urban core, which positioned it to become an ideal transfer station for the region’s transition from dope to pills, then back to dope. It was the perfect incubator for the opioid epidemic—a cultural and geographic crossroads. It was big enough for users to easily forge drug connections and yet small enough for the drug dealers to hide out.

“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.

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 we’re prescribing to ever- and ever-younger children, some kids as young as two years old,” said Lembke, the addiction researcher.

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.

By 2012, fully one-third of his campers were on meds, mostly ADHD medications, antidepressants, and antipsychotics. “What happens is, we’ve changed our whole culture, from one where kids don’t take pills at all to one where you’ve got a third or more of kids who are on pills to stay well because of what are believed to be chronic health conditions,” Burton said. “They get so used to taking pills that eventually they end up using them for a recreational high.”

Across the nation, police chiefs and sheriffs were beginning to lament, “We can’t arrest our way out of this epidemic.” That sentiment illuminated the folly of the decades-long War on Drugs, in which drug users are arrested four times more often than those who sell the drugs.

For forty years, Baltimore had been a prime staging area for dealers moving drugs, especially heroin, along the East Coast. Its port was an entryway for international drug smuggling. Another trafficking artery was Interstate 95, which connected Baltimore to cities from Miami to Bangor, Maine,

the FDA approved a new high-potency, long-acting version of hydrocodone, Zohydro ER, even after its own expert panel voted 11–2 against it, noting that the drug, which lacked an abuse deterrent, could lead to the same level of addiction and abuse as OxyContin had in its original form. The FDA concluded that “the benefits of this product outweigh the risks.”

the FDA denied her secondary request, which was to have the drug limited to severe, acute, or terminal pain—and not prescribed for chronic use unless all other treatments had first been explored, guidelines most other countries in the world have adopted. Americans, representing 4.4 percent of the world’s population, consume roughly 30 percent of its opioids.