THE OVERDOSE EPIDEMIC that the United States struggles with today is different from any drug problem the country has experienced before. As veteran Virginia journalist Beth Macy writes in her new book, Dopesick:
By 2014, the suburban heroin-dealing scene had become entrenched in Roanoke’s McMansion subdivisions and poor neighborhoods alike. But the largest dealers weren’t twice-convicted felons […] with elaborate dope-cutting schemes, multiple cars, and hired mules. They were local users […]. The rich kids were crashing alongside the poor kids on friends’ couches (the lucky ones, anyway), all of them cowering before the morphine molecule and beholden to its spell.
The Centers for Disease Control and Prevention recently estimated that 72,000 people in the United States died after taking drugs in 2017, up from roughly 15,000 two decades earlier. In Dopesick, Macy brings clarity to what she describes as the “perfect storm” that created one of the most pressing health emergencies the United States has ever faced.
She details the misleading marketing campaigns pharmaceutical giant Purdue Pharma used to convince the United States’s doctors that its prescription painkiller OxyContin was only addictive in a small minority of cases. Macy notes that this occurred just as medical organizations were adopting pain as the “fifth vital sign” and hospitals had begun tying patient satisfaction to doctor reimbursement. Meanwhile, factory towns across the country were in decline and dwindling economic opportunities left increasing numbers of people in pain, both physical and mental. As Syracuse University professor Shannon Monnat is quoted saying in the book: “When work no longer becomes an option for people, what you have at the base is a structural problem, where the American dream becomes a scam. […] If the economic collapse was the kindling in this epidemic, opiates were the spark that lit the fire.”
Eventually, government regulators realized that OxyContin was just as addictive as any other powerful opioid. A crackdown on prescribing ensued, but by then it was too late. Tens of thousands of people were addicted. When doctors cut off their supply, many patients went looking elsewhere, and found heroin that dealers were waiting to sell them on the street. “Three hundred thousand Americans […] died of an overdose in the past fifteen years,” University of Pittsburgh public health dean Don Burke notes in the book. “Lacking dramatic interventions, the same number would die in just the next five years.”
Woven throughout Macy’s story is a riveting and heartbreaking human narrative that follows two families as their children fall deeper into drug addiction. Pharmaceutical opioids prescribed by doctors have not played a central role in every corner of the United States’s overdose epidemic to the same extent that they have in the areas of Appalachia that Macy covers. But the story of Virginia she recounts — where three citizens died of drug overdoses every day in 2016 — aptly captures the region’s struggle. And, regardless of how any one area got here, citizens from every walk of life are now in this fight together.
Macy recently spoke to me about Dopesick and America’s opioid epidemic, which continues with no end in sight.
TRAVIS LUPICK: In Dopesick, you recount the role that pharmaceutical companies played in the United States’s opioid epidemic, but you also suggest that the decline of factory work was a significant factor. Can you explain how economic hardship in Appalachia relates to the problem of over-prescribing?
BETH MACY: What really made me understand how those issues are so entwined was the story of a woman in the coal fields. She had lost her job and had had gallbladder surgery. And she became addicted because she was over-prescribed. She was told, even the in middle of the night, to get up and take Percocets for the pain. And, at the end, by the time nobody wanted to prescribe to her anymore, she realized that her neighbor, who had just lost her job when a textile plant closed, had some ailment and could probably talk her doctor into giving her OxyContin. She could then sell them to her. So the woman who had surgery was now taking OxyContin to stave off dope sickness, while the older woman who had lost her job in the textile plant now had money to buy her blood pressure medicine and pay her rent.
That sort of thing happened a thousand times in these distressed areas where there had been a lot of workplace injuries and people were already taking opioids. Pharmaceutical reps for Purdue Pharma really focused a lot of their marketing efforts on those areas.
Is it possible, because the economic decline of these areas has so many people in such a state of pain, that some other enterprising dealer other than the pharmaceutical companies would have moved in to capitalize on that pain?
That could be. But we have the facts that we have, and it was Purdue Pharma that came in with this new drug that was heralded as being addictive in less than one percent of cases, which we now know is bunk. And the FDA allowed them to make the squishy claim that, because of a time-release mechanism, OxyContin was believed to reduce liability of abuse. And right away, in these distressed regions, the cops started noticing the drug being diverted and sold on the streets.
While it tells a larger story of how the United States’s opioid epidemic developed, Dopesick is also simply the story of a small group of recent high school graduates who form a loose gang of friends via dealers and drug circles, and who find themselves struggling with increasingly problematic addictions. The way that narrative takes shape, was that intentional or organic? Was there something specific you were trying to say by focusing on that one small group?
I had been covering these two families that came out of Hidden Valley, which is a wealthy suburb outside of Roanoke, Virginia, where I’ve been a reporter for 30 years now. I had been following these two families, and after I wrote a series in 2012 that ran on the front page of the paper three days in a row, readers sort of spit out their coffee and said: “What? Holy crap. Wealthy white people are using heroin?” And so, later, when I decided this was going to be my third book, I had these relationships that I’d already made.
I’ve kept in touch with the mothers, and I even continued to keep in touch with Spencer Mumpower after he went to prison. And then I went back to the prosecutors, and that’s when I learned about the Ronnie Jones case, just up the valley a few hours. When I took that story and added it to the story I’d been following of this single cell of Hidden Valley users, and then traced it all back to the beginnings of OxyContin landing in the coal fields (which also has a big local tie because it was the Roanoke US attorney’s office that was responsible for the investigation that led to the Purdue Pharma plea agreement in 2007), I had what I thought was a story of three Virginia communities. But, really, it was a microcosm of what has happened in America.
You obviously grew very close to some of the subjects of your book. You write about how there were moments when journalistic objectivity was lost. How did you wrestle with that? How did that change the story you told? I wonder if it made for a better story.
It probably made for a better story. I think you always have a better story when you go right up to that ethical line. Otherwise, you’re not getting close enough. Walt Harrington, who’s one of my favorites of all time — he used to write features for the Washington Post and is a professor now — he said, “If you’re not sweating at night about what to include and what not to include, you haven’t gotten close enough.” You’ve got to get close. But it hurts to get close.
I got close to these people. Some of them died before I had a chance to type up my interview notes on them. You’re dealing with families in crisis and they’re vulnerable. Many people, especially from the wealthier sections, they’re still cloaked in this sense of stigma and shame.
There were a lot of negotiations. “Well, don’t put that in.” And my goal was always, “How do I tell a truthful story?” This problem is so bad now, we just need to put it all on the table. But you don’t want to force people who aren’t willing to do that. So there were a lot of negotiations.
You also wrote this book through the lens of a parent. There are several points in Dopesick where you assess a specific policy response to problematic drug use — medically assisted treatment (MAT), for example, which is still controversial in some areas — by asking yourself what you would want for your children.
A drug court judge said to me, “Beth, what do we do?” He was having a heck of a time getting his prosecutor to sign off on allowing drug-court probationers to go on MAT. I said, “Judge, I know they’re against it, I know your prosecutor is against it. But, if it was my kid, I would want them to be alive and maybe a little bit high on MAT, but at least alive.” And he said, “I feel the same way.” So we would talk about that. What would we want for our own kids? And so I tried to emphasize that viewpoint in the book. Many people I talk about still don’t believe in MAT. It’s tough. There’s a real ideological divide out there still.
For me, the most frustrating sections of the book — some that elicited outright anger — were those covering options for treatment, and your recounting of how difficult it is for many people to access treatment for an addiction issue. Did you feel the same frustration?
There are all these barriers to treatment. Massive barriers. I thought it was my job to show people that. Tess Henry, the first time I met with her in 2015, she wanted to show people that. I don’t think I had a book proposal yet. I said, “I don’t know what I’m going to do with this, but I know that if we spend time together, I’m going to learn a lot about what you and other users go through.” And she said, “Yeah, I’m all about that. People have no idea. They just think I’m this addicted piece of crap. They have no idea what I struggle with.”
There were many months when I didn’t see her or have contact with her. But I was always in contact with her mother. And her mother, a health professional — a very smart woman, very assertive — had such a hard time getting access to treatment for her daughter. And, ultimately, that left her daughter in this world of criminal gangs and prostitution, and that ended with her murder on Christmas Eve. But I didn’t have any big agenda, I swear. I just wanted to tell the truth.
I wrote a book about the role that harm reduction should take in response to America’s opioid epidemic. Harm reduction does not receive a lot of attention in Dopesick, but toward the end, you do suggest that programs such as MAT should receive more attention from policymakers than they do currently. What role should harm reduction play going forward?
I think it’s huge. Look at the recent numbers on overdoses that came out recently: 72,000 people died in 2017. And the three states that have really good harm-reduction programs, that have access to MAT, and that expanded the Affordable Care Act early — Massachusetts, Rhode Island, and Vermont — are the only ones that have shown a slight decrease in drug overdoses. They also happen to be places where there are more syringe services and recovery.
Here where I live, in Roanoke, the police chief came out recently against syringe exchange. At my book launch event, we had three city councilors, and I told this story and said, “Syringe exchange isn’t just enabling, quote, addicts, unquote. It’s also getting dirty syringes off the street. It’s important to get people who are addicted to drugs into a comfortable and low-threshold facility where they can be safe, get tested for diseases, get treated if they have them, and, hopefully, always, the goal is to get them into a good treatment program.”
Many of them right now are living homeless, prostituting themselves, are involved in criminal enterprises. They’ve worn their families out. That’s why I always go back to what Tess told me. She said, “We need urgent care for the addicted.” And she’s exactly right. They need to be able to go to a strip mall — just the way they could when they got their initial opioids — and get help. But where’s the urgency? I’m not seeing the urgency. I’m hoping that my book will inspire it.