In her first book, 2014’s Factory Man, Beth Macy used the colorful story of John Bassett III to illustrate globalization’s impact on one small Appalachian town. Bassett is a third-generation Virginia furniture manufacturer who successfully fought to keep his company operating on American soil and to preserve his workers’ jobs in the face of a flood of cheap imports from China. Furniture is of course not the only industry that’s collapsed in Appalachia, an area that Macy, who was a longtime reporter for the Roanoke Times, knows well; the decline of coal and the outsourcing of other manufacturing jobs have decimated the region’s economy.
The depressed communities of central Appalachia, in addition to depressed rural communities in Maine and along the Rust Belt, were ground zero for the opioid epidemic, and the ever-growing crisis is the subject of Macy’s wrenching new book, Dopesick: Dealers, Doctors, and the Drug Company that Addicted America. Previous epidemics, like crack cocaine in the 1980s, originated in the inner cities and fanned outward to suburban and rural areas. Not so for the opioid epidemic, which took root in regions where the vanished jobs were particularly dangerous and often resulted in injury. The “perfect storm fueling the opioid epidemic,” Macy writes, has been “the collapse of work, followed by the rise in disability and its parallel, pernicious twin: the flood of painkillers pushed by rapacious pharma companies and regulators who approved one opioid pill after another.”
Combining her sharp journalistic skills with deep research, Macy dissects all of these causes and their ensuing disastrous effects, giving Dopesick ambitious scope. (Macy also credits those authors who paved her way, including Barry Meier, who covered the burgeoning epidemic for the New York Times and wrote 2003’s Pain Killer.) After a brief history of opiates, Macy turns to the development of OxyContin by Purdue Pharma in 1996 and the pharmaceutical industry’s relentless marketing of opioids, charting the industry’s success in transforming medications that had been used to treat terminal patients into pills prescribed for everyday aches and pains. One of the book’s most tragic subjects got hooked on opioids after she went to urgent care with a case of bronchitis.
The effectiveness of this marketing strategy is conveyed by the fact that by 2000, family doctors surpassed oncologists as the country’s largest group of OxyContin prescribers. In 2000 alone, Macy reports, pharmaceutical companies spent a staggering $4.04 billion in direct marketing to doctors. Purdue didn’t merely carpet-bomb the medical community: the company sent its drug reps directly to doctors that it knew prescribed the most competing painkillers, like Percocet and Vicodin, based on information it purchased from a data-mining firm. Macy cites a tiny West Virginia town, with a population of fewer than 400 people, whose pharmacy was shipped almost nine million hydrocodone pills within a couple of years. When Purdue finally introduced an abuse-resistant Oxy in 2010, addicts turned to heroin and fentanyl, which were cheaper and easier to obtain, in order to stave off the excruciating withdrawal symptoms, “dopesickness,” that lend the book its name. The result is that drug overdose is now the leading cause of death of Americans under the age of 50. (In 2007, Purdue paid $600 million in fines to settle charges that it had misled regulators and medical professionals about OxyContin’s addiction and abuse risks.)
While the statistics are jarring, it is in conveying the epidemic’s human toll that Macy excels. She spends hours with addicts, dealers, law enforcement agents, and grieving mothers, one of whom took away her son’s car and removed every door in their house, even in the bathrooms, in a desperate effort to prevent him from doing heroin. He suffered a fatal overdose at 21. Macy also gets to know the friend who sold the young man his last bag, following him as he prepares to go to prison. He tells the author that as a teenager he did heroin before drinking his first beer; the heroin was easier to get.
Macy deploys science and personal stories to convey the formidable challenge of overcoming opioid addiction, which she calls “a lifelong and typically relapse-filled disease.” As one mother of an addict tells her, “There is no love you can throw on them, no hug big enough that will change the power of that drug.” Despite the vast human toll, the national response has been shortsighted and inadequate. Macy is critical of both an overly punitive criminal justice system that imprisons people who need treatment and a misguided health care system that “overtreats people with painkillers until the moment addiction sets in—and health care scarcity becomes the rule.” Treatment, for those who can afford it, most commonly conforms to an abstinence-based 12-step model, even though medication-assisted therapies have proven more effective. Macy bears witness as exhausted family members sink all of their resources into trying to help loved ones, often to no avail.
One of Macy’s sources, a tireless judge in a Virginia drug court, presses her during their interviews to tell him anything she’s learned from her reporting that he can feel hopeful about. But hope is hard to come by in this crisis: one expert tells the author that charts predicting future overdose deaths show a “continuous, exponential, upward-sloping graph.” Still, the conviction that Macy expresses at the outset—that “until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment”—lends the book its urgency. Tom Hanks is currently producing an HBO miniseries based on the triumphant story told in Factory Man. Dopesick is compassionate and humane and has its share of heroes doing all they can to heal their small, forgotten corners of the country. But were the book to be adapted for the screen, the resulting movie would be heartbreaking and bleak, short on stirring victories.