"Dopesick: Dealers, Doctors, and the Drug Company That Addicted America" by Beth Macy; Back Bay Books (400 pages, $17.99)
If you don't know anyone who has died of an opioid overdose, odds are you will.
By 2016, Beth Macy writes in "Dopesick," her riveting nonfiction account of the epidemic, "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 50, killing more people than guns or car accidents, at a rate higher than the HIV epidemic at its peak."
The United States has seen widespread, deadly drug abuse before, from the "soldiers' disease" of morphine addiction among veterans of the Civil War to the crack plague of the 1980s.
But the current crisis is different, as Macy makes clear in this deeply researched and often moving book. It began with legal medications, aggressively marketed by huge pharmaceutical corporations that distributed them in mind-boggling numbers far out of proportion to the populations of the communities where they were prescribed. It's different, too, in that its victims have been predominantly white and spread across all income classes. It moved from poverty-stricken towns in Appalachia to prosperous suburbs with sickening speed.
Macy, an award-winning journalist who lives in Virginia, has written two previous nonfiction best-sellers, "Factory Man" and "Truevine," both anchored in Appalachia. Although Dopesick tells a national story, she focuses on its genesis and continuing impact in her region.
In a brief history of American drug abuse, she notes that many new forms of opioids were intended to counteract the harmful effects of older ones. Heroin, for example, was first marketed as a safe, nonaddictive alternative to morphine. Both were legal until 1914, sold over the counter for everything from postsurgical pain to teething babies.
The current crisis was born with the introduction in 1996 of OxyContin, a synthetic opioid marketed as better for cancer pain than older drugs like Percocet and Vicodin. But it was also touted to doctors as safe – "with addiction rates of less than 1 percent" – for things like dental surgeries and sports injuries. At a time when pain management was becoming a major goal in medicine, called the "fifth vital sign," Oxy was the answer.
OxyContin was patented by Purdue Pharma, a U.S.-based international corporation owned by brothers Mortimer, Raymond and Arthur Sackler. The company accelerated the new drug's success with aggressive sales techniques, from hiring sales reps for their model-level good looks and paying them enormous bonuses, to picking up the tabs for countless fancy meals and posh vacations for doctors and their staffs.
Macy documents how the drug took off like a rocket in small, achingly poor towns in Appalachia, where she interviews people whose families have lost multiple members to overdose, from teenage athletes to former coal miners in their 80s.
A cemetery owner in Virginia calls the drug Oxy Coffin, because he has buried so many opioid victims – including his son, who died after eight years sober of untreated hepatitis C. A young EMT tells Macy his work consists mainly of dispensing narcan, an overdose-reversing drug. He decided to train for rescue work after the day in his high school freshman English class he "heard the double thump of two classmates seated behind him hitting the floor. They'd overdosed on OxyContin during a lesson on grammar and punctuation."
Macy follows the opioid crisis to well-off Virginia suburbs as well, where some parents have spent tens of thousands of dollars to send their addicted children to rehab multiple times. She finds that almost every addicted 20-something she interviews got their start in prescription abuse with drugs like Ritalin and Adderall. The stimulants are meant as study and behavioral aids, but kids soon discover that taking the pills will let them drink alcohol all night without passing out. Selling a few spare Ritalins to kids without a scrip slides them into pilfering their grandparents' postsurgical opioids, and the spiral goes down from there.
Wherever they're from, when these addicts can't get access to legally manufactured opioids, they use heroin and even more dangerous street drugs, like the dizzying number of varieties of fentanyl – some so toxic first responders and police have to don hazmat suits, because a touch can kill. Anything, Macy writes, to avoid the addicts' greatest fear: the brutal pain of withdrawal, the "dopesickness" that gives the book its title.
Macy searches for solutions to the problem. She writes that the best results seem to come from medication-assisted treatment, or MAT, which employs the monitored use of drugs (such as methadone, naltrexone and buprenorphine) that block narcotic effects, reduce withdrawal or both. Macy also argues for Medicaid expansion; in states that have implemented it, addicts who can't afford other health insurance are able to get treatment.
She finds inspiring heroes, like small-town doctor Art Van Zee, who has devoted the last couple of decades to trying to hold back the tide. But, she writes, there is no large-scale, unified effort to fight this growing crisis, from the medical or law enforcement communities, or from politicians.
President Donald Trump has repeatedly refused to declare the epidemic a national emergency, which would allow funding to combat it. His only proposed solution is, he says, "talking to youth and telling them: No good, bad for you in every way." He has claimed his planned border wall would decrease the flow of drugs, but as Macy makes abundantly clear, the epidemic was created by diversion of the oceans of legally manufactured pills from U.S. pharmaceutical companies, and many illegal opioids, especially forms of fentanyl, are made in China and distributed through online mail order.
Solving the problem is also a matter of awareness, and Macy points out the bitter irony that, just as small towns and suburbs were being invaded by the epidemic, newspapers there that might have covered it have withered, leaving people unaware and hence vulnerable.
Sometimes larger media focus on opioid addiction, especially when celebrities like Philip Seymour Hoffman and Prince die of it. It shows up in the news most often these days because of legal strategies to stop the flow and hold manufacturers responsible. Purdue Pharma and the Sacklers are involved in a maze of big-dollar lawsuits, as are a number of other drug companies, distributors and pharmacies.
But for many Americans, it's a crisis flying under their radar. Macy tells much of her story through the human beings affected by it, like Philadelphia father Ed Bisch. In 2001, he got a frantic call from his daughter about his 18-year-old son, "a high school senior, a soccer player with decent grades and plans to attend a local culinary school." Bisch suspected his son might be drinking, maybe smoking pot – until, Macy writes, the day he got that call.
"The first time Ed Bisch heard the word 'OxyContin,' his son was dead from it."