A Ground-Level Look at the Opioid Epidemic

Fewer than 50 pages into Beth Macy’s “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America,” one of the many opioid users she talks to — this one a mother in Virginia — explains how her addiction started in the early 2000s, after routine gallbladder surgery. “The doctor didn’t force me to take them,” she said of OxyContin and Percocet, two powerful painkillers she was instructed to take concurrently. But her doctor, she assumed, was a “high-standard person, someone you’re supposed to trust and believe in.”

If you want a glimpse into how the opioid crisis began, the woman’s words are a good place to start. She was aware of her own choice in the matter, but her physician instructed her to double up on highly addictive narcotics. An expert, someone supposed to know better, had betrayed her trust.

Books like “Pain Killer,” by Barry Meier, a reporter for The New York Times, and “Dreamland,” by journalist Sam Quinones, have covered the opioid crisis in detail, but they appeared before the 2016 election, when the places in the country most affected by the epidemic went for Trump. With “Dopesick,” her third book after “Factory Man” and “Truevine,” Macy has waded into a public health morass that has also become a political minefield. Commentators on the left have pointed out the gaping discrepancy between the sympathy extended to today’s opioid users, who are mainly white, and the brutal, racist handling of the war on crack.

“Dopesick” touches on these political developments, but its emphasis lies elsewhere. Macy’s strengths as a reporter are on full display when she talks to people, gaining the trust of chastened users, grieving families, exhausted medical workers and even a convicted heroin dealer, whose scheduled two-hour interview with the author ended up stretching to more than six hours.

Macy captures an Appalachian landscape in a state of emergency and in the grip of disillusionment, but there’s little here that’s new. Indeed, that’s part of her point — not enough has changed.

We now know that things didn’t work out that way. Users soon learned that the coating could be rubbed off to reveal the small pearl of pure oxycodone inside. That pearl could be crushed, and then snorted or injected. Drug overdoses, fueled by opioid abuse, are now the leading cause of death for Americans under 50. As it happens, the history of painkillers is full of doctors and drugmakers testifying to the utmost safety of newfangled products that turned out to be downright perilous. In the mid-1800s, the physician who invented the hypodermic needle insisted that injecting opiates was safer and more precise than eating them; his wife became the first person to die from an injected-opiate overdose. Fifty years later, heroin was touted as nonaddictive, a miracle cure, and dispensed to women with menstrual cramps and for babies with colic.

Macy started reporting her story in 2012, when what had begun as a problem with pain pills had mutated into a full-blown heroin epidemic. After a $600 million settlement in 2007, Purdue reformulated OxyContin so that the pills turned into a gooey, unsnortable mess when crushed. Crackdowns on pill mills also made opioid painkillers harder to procure. Users, faced with the wrenching pain of withdrawal and the attendant vomiting and diarrhea, turned to heroin, a substance that was cheaper and easier to get.

In Roanoke, Virginia, where Macy lives, “no one was paying attention to heroin arrests when they only concerned the children of inner-city black families,” she writes. When white people in the suburbs started using and dying, however, the media took notice. Macy meets police officers who insist it was the heroin dealers who brought the opioid trouble to their towns. A couple of hours north of Roanoke along the I-81 corridor is Woodstock, Virginia, where 94 percent of the residents are white. A law enforcement agent there confidently declared that the arrest of Ronnie Jones, an African-American newcomer and heroin dealer “who’s making the whole town dopesick,” would make a real difference.

But the problem, as Macy’s own user-subjects point out, didn’t start with one guy. Before Jones arrived, a number of people were driving up to Baltimore to buy heroin; he might have saved them the trip, but they were already hooked. As children, some of them had been prescribed Ritalin for ADHD; later, as teenagers, they were prescribed powerful painkillers for injuries. (One mother, whose son died of an overdose, describes taking her 15-year-old daughter to an urgent-care clinic for a sprained thumb and leaving with a prescription for a 25-day supply of oxycodone.)

Macy agrees that Jones may have helped make a bad situation worse, but she shows that the roots of the crisis extended far beyond him. In Roanoke, the largest heroin dealers weren’t drug kingpins looking to make money. “They were local users,” Macy writes, “many of them female, dispatched to buy the heroin from a bulk dealer out of state, in exchange for a cut.”

There’s a great deal in “Dopesick” that’s incredibly bleak, but the most chilling moment for me was a quote from one of Macy’s journalist friends. Synthetic opioids had allowed this woman, despite a severe curvature of her spine, to lead an active life without risky surgery. She resented new rules that made it more onerous for her to get the pills. “My life,” she told Macy, “is not less important than that of an addict.”

That Macy’s friend would see the situation in such stark, zero-sum terms doesn’t bode well for ending the opioid crisis, which Macy suggests will require a profound transformation of how we understand who we are in relation to one another. But zero-sum thinking is, in some ways, a logical response to a dysfunctional system that seems to lurch from one extreme to another, from coddling pain to nearly criminalizing it. As one addiction doctor tells Macy, “Our wacky culture can’t seem to do anything in a nuanced way.” Whatever the fix may be, it won’t be quick.

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Publication Notes:

“Dopesick: Dealers, Doctors, and the Drug Company That Addicted America”

By Beth Macy

Illustrated. 376 pages. Little, Brown & Co. $28.