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

Dopesick: Dealers, Doctors, and the Drug Company that Addicted America by Beth Macy | Little, Brown and Company, 384 pages, Hardcover, August 2018, ISBN 9780316551243

Primum non nocere. First, to do no harm. It is the backbone of bioethics and medical education the world over.

The name “Heroin” was trademarked by the pharmaceutical giant Bayer, the first to commercially manufacture the opium-derived drug. Released by the company in 1898 (a year before its release of aspirin), it was advertised as a "non-addictive morphine substitute" for pain relief, suitable for everything from headaches and menstrual cramps to baby colic. Since they claimed it was non-addictive, it was also marketed as a remedy for the nation’s growing morphine crisis, often known as “soldier’s disease,” because its use was so high among Civil War veterans, and “particularly severe among white Southerners in small cities and towns” devastated by war and the upending of an economy built on human slavery.  

“By 1900,” just two years after heroin’s release, Macy tells us that “more than 250,000 Americans were addicted to opium-derived painkillers.” Heroin, it turns out, was actually far more addictive than morphine had been, and the addiction rate among its users proved to be catastrophic. By 1914, new limits were put on its sale, and it was outlawed in the U.S. altogether in 1924.

All this I learned in the first 25 pages of Beth Macy’s new book, Dopesick. In the following decades, Macy tells us:

The “respectable” upper- and middle-class opium and morphine addicts having died out, the remaining addicted were reclassified as criminals, not patients.

This would eventually lead to a global War on Drugs, mass incarceration, and what the Global Commission on Drug Policy has deemed “devastating consequences for individuals and societies around the world.” If I would have stopped reading after those first 25 pages, I would have left the book shaking my head at the follies of an earlier medical era and the ripples it has had on society. And I would be armed with a few entertaining etymological facts, like that the term “junkie” comes from those who sold scrap metal to fund their habit, and that the word “hipster” began in the beatnik subculture, which took it “from the Chinese opium smoker of the 1800s, who’d spent much of his time smoking while reclining on one hip.” I’d probably even be able to say I was entertained.

Unfortunately, history would echo itself a century later, with equally grim consequences on human beings, families, and communities. And that is the story Macy tells so intimately and effectively in Dopesick. The book is one of the best reported and most well written I’ve ever read, but it is also devastating—befitting its topic.   

Because the medical history and human devastation of Bayer’s commercial foray into heroin was either forgotten or unheeded, in 1995, the FDA approved another opioid painkiller, OxyContin, manufactured by a less well-known pharmaceutical company based in Stamford, Connecticut, Purdue Pharma. Following what Macy calls a “[s]eismic shift toward thinking of patients as health care consumers,” and a pain management movement that introduced a “pain score” on patient surveys to rate their experience, the way was paved for opioid painkillers to make a comeback.  

The release of OxyContin in 1996 would mark the beginning of a wave of addiction similar to that which gripped the nation a century earlier, moving from rural America to the nation’s cities and suburbs. Macy traces this wave back to those rural roots—where overdose rates still remain 50 percent higher than in urban areas—and to its birthplace in central Appalachia. It was there that, using data on where pain prescriptions were most commonly written, Purdue Pharma found the coalfields of western Virginia, with its high rates of people on both disability and Medicaid. Its economy hollowed out by globalization and the decline of coal, many found the best way to survive was on disability. It was a trend not unique to Appalachia:

Disability claims nearly doubled from 1996 to 2015. 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.

But it was particularly severe there, as was the literal pain many experienced from working in coal. So it was in places like Lee County, Virginia, where Purdue turned its significant marketing muscle first. The eldest brother in the family-owned company had “pioneered the idea of showering doctors with favors and funding experts to back drugmaker’s claims in the 1960s,” a system they put into full force with the release of OxyContin. Business was soon booming.

Sales-rep bonuses grew exponentially, from $1 million in 1996 the year OxyContin hit the market, to $40 milion in 2001. New patients were given OxyContin “starter coupons” for free prescriptions—redeemable for a thirty-day supply—and Purdue conducted more than forty national pain management and speaker-training conferences, luring doctors to resorts from Boca Raton, Florida, to Scottsdale, Arizona. The trips were free, including beach hats with the royal-blue OxyContin logo. More than five thousand doctors, nurses, and pharmacists attended the conferences during the drug’s first five years—all expenses paid.

Reps who called on “indiscriminate prescribers,” Macy tells us, could “earn as much as $100,000 a quarter in bonus pay alone.” Purdue, like Bayer had a century earlier, claimed the drug was non-addictive, using an out-of-date, out-of-context quote from a medical journal to claim an addiction rate of less than one percent. But $100,000 is also, incidentally, the amount Purdue put into a grant to create a statewide prescription monitoring program in Virginia when addiction to its product began to soar (systematic reviews have since pegged the true addiction rate as high as 56 percent), and for another grant offered to Lee County for treatment and law enforcement—a grant turned down as “blood money” by a group of local activists.

People on the front lines of the epidemic like Art Van Zee and Sister Beth Davies, a country doctor and a nun in Lee County, saw the destruction first-hand. Van Zee lobbied hard to restrict prescriptions to severe cases, like cancer, and for a reformulation of the pill to make it less addictive, similar to what had been done to the painkiller Talwin in 1982—adding “a narcotic blocker, or antagonist, called naloxone, to the mix,” which “immediately reduced the drug’s diversion and misuse.” Regulators were slow on the former, and Purdue refused to take that latter step for more than a decade, and did so only when its patent was set to expire. It was too late. Flooding the county with as many pills as it sent to areas five times its size, Oxycontin was soon everywhere:

Within two years of the drug’s release, 24 percent of Lee High School juniors reported trying OxyContin, and so had 9 percent of the county’s seventh graders.

Users soon found that they could easily crush the pill and snort or inject its contents for a quicker, more intense high. There was soon a thriving black market for the pills, and the epidemic would spread quickly from the hills and hollows of western Virginia to more affluent suburbs and cities—cities like Roanoke, where Macy works as a journalist. And, as the pills finally became more regulated and harder to get, and reformulated to make them less prone to abuse, heroin started to fill the void. “The region’s pill problem,” writes Macy, “had become a full-fledged heroin epidemic in the span of a few months.”

Once addiction takes hold, it can spread quickly through social circles, as users become small-time dealers and get others hooked to support their habit. And this cycle lasts a lifetime:

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.

“Four out of five heroin addicts come to the drug through prescribed opioids,” writes Macy. So how did OxyContin ever get approved in the first place? The process, as she describes it, was full of blatant conflicts of interest. The FDA’s top examiner when OxyContin was approved, Curtis Wright, would be hired as a consultant by the company two years after approving the drug. And a Milwaukee Journal Sentinel investigation found that “FDA regulators and Big Pharma executives had been quietly holding private meetings at expensive hotels at least annually since 2002, through a drug-industry-funded nonprofit.” Macy continues:

The same Journal Sentinel reporter, John Fauber, would also uncover how the American Pain Society and the American Academy of Pain Medicine pushed for expanded use of opioids for long-term chronic pain while taking in millions from the companies that made them.

The results of a 2012 Senate investigation into such relationships remains sealed. One U.S. attorney, Jay McCloskey, did have some success in challenging the company’s promotional techniques early on, “only to leave his post in 2001 to work as a consultant for—wait for it—Purdue Pharma.” And the lobbying didn’t end once the drug was unleashed onto the world. Once released, Purdue’s medical director called local reporters to complain of crime coverage tied to OxyContin addiction. The company bullied national journalist Barry Meier after his book, Pain Killer, was released, and successfully lobbied his employer, The New York Times, to remove him from the beat, claiming he had a financial conflict of interest now that he had a book for sale on the topic. Purdue hired Rudy Giuliani—who had (ironically looking back on it) made fighting the drug war a central theme of his mayoral run—to represent them, but Giuliani couldn’t save them from the eleventh largest fine ever paid by a pharmaceutical company, and the guilty charges three of its executives had to cop to as part of the plea bargain to keep them out of court in western Virginia. The Sackler family, which owns Purdue, probably didn’t feel much pain (their “rank on America’s Richest Families slid from sixteenth to nineteenth on the Forbes list”) but the rest of the country has:

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.

Not only that, but in 2017, the opioid epidemic had “a financial toll of $1 trillion as measured in lost productivity and increased health care, social services, education, and law enforcement costs.” Meanwhile, the economic conditions that provided the kindling that fueled the epidemic don’t seem to be improving. The system that has made it easier to become addicted than to find treatment isn’t improving much, either, nor is the stigma against the disease of addiction lessening. There is inspiration to be found in those who are fighting this on the ground, in their families and communities, and their stories are courageous and often truly beautiful, but they need more help.

I kept looking for a set of larger, ultimate solutions, similar to those found in Macy’s first book, Factory Man, that would save everyone like the factory owner in that book saved hundreds of jobs in his Virginia furniture business. But this is not a book that ends with a ray of light and easy path forward, and it is clear in the end that this is not a problem that will go away in our lifetime. Macy examines treatment options, the healthcare implications, and some potential healthcare solutions (in as much as harm reduction, which is usually all that can be hoped for, counts as a solution), as well as the relative success of Portugal’s decriminalization efforts. Her ultimate answer, "a reinvigorated democracy that provides a pathway for meaningful work, with a living wage, for everybody," is systemic, and something to work toward. Meanwhile, the epidemic continues to spread every day, killing 300,000 people over the last 15 years, and on pace to kill an additional 300,000 over the next five. Opioid addiction is a dark, devastating, and deadly disease, and Dopesick intimately exposes that reality for the individual lives caught up in it. Macy's in-depth, personal portraits of those who have been lost, and the families members left behind, are both a gut punch and—beyond the righteous anger at those responsible—the heartbreaking beauty of the book. 

Primum non nocere. First, to do no harm. It is supposedly the backbone of bioethics and medical education the world over. But it is being left to the families and communities affected by the modern opioid epidemic—and almost every community in America has been—to do as much as can be done to reduce the harm already done by the “Dealers, Doctors, and the Drug Company that Addicted America”—to heal the hearts and addicted brains of those around them.