When 27-year-old Debbie Honaker went to her doctor in Lebanon, Virginia, after a routine gallbladder surgery in the early 2000s, she was prescribed “Oxy tens” — 10 milligrams of OxyContin. At her next visit, it turned into 40s. Then she graduated to Percocet. Soon, she began stealing pills, then buying them from Medicaid patients for $1. “At the end of your journey, you’re not going after drugs to get high; you’re going to keep from being sick,” she says.
Honaker’s story is just one of many in author Beth Macy’s new book Dopesick: Dealers, Doctors, and the Drug Company that Addicted America, which chronicles the 20-year history of the opioid epidemic, starting with the dawn of OxyContin in 1996 and ending with grim statistics: more than 42,000 dead from opioid overdoses in 2016 alone and expert predictions that 300,000 will die in the next five years.
Macy’s first book, 2014’s Factory Man, underscored the toll of offshoring business on America’s rural communities. In Dopesick, Macy, a Roanoke-based journalist, continues to follow American workers, investigating how those who have lost factory and mining jobs have been hit especially hard by the opioid epidemic.
The villains of Dopesick are the pharmaceutical companies — namely Purdue Pharma, the company that sold OxyContin — corruptible doctors, and a lax Food and Drug Administration. The victims? The rest of America, especially those in economically distressed parts of the country.
America is sick, Macy argues, and too many people have looked the other way during the worst drug epidemic in its history.
I spoke with Macy to better understand the history of the epidemic, its real-world impact, and what is missing from our national conversation on opioids.
Our conversation has been condensed and edited for clarity.
You write about central Appalachia as “the birthplace of the modern opioid epidemic.” What are the characteristics that made a region like Lee County, Virginia — which began seeing teenagers overdose in the late ’90s — susceptible to the OxyContin epidemic?
It’s the same thing if you look at the other initial hot spots. In Machias, Maine, a logging and fishing community, there were also many people already on painkillers from legitimate injuries due to these manual labor jobs. But in Appalachia, in particular, you had trade deals like NAFTA in ’94, and then China joined the WTO in ’01, and so you saw the furniture and the textile mills closing and the jobs going away — and at the same time, a huge rise in disability.
Now, 57 percent of the men of working age in Lee County are unemployed. As this is happening, this whole notion that we were horribly undertreating pain began being pushed by big pharma. Suddenly you couldn’t go and visit somebody in the hospital where there wasn’t a whiteboard where they would ask you to rate your pain on a scale of 1 to 10, or draw a smiley face or a frowny face.
All these things sort of converged: the joblessness, the rapacious behavior of big pharma, Purdue Pharma in particular. One of the first cops I interviewed said, “Oh, yeah, people were walking down the street with green and orange smudges on their shirt.” Orange was the color of an Oxy 40 mg and green for the Oxy 80 mg. They had held the pills in their mouths to soften up the time-release mechanism coating so they could get the euphoric rush of an entire pill all at once, then wiped the coating off on their shirtsleeves.
I’m also interested in how doctors were incentivized. They were basically taking bribes — going on Caribbean vacations, for instance, hosted by pharma companies. Has there been a crackdown on doctors? What kind of gifts are they allowed to accept from sales reps?
That’s changed in more recent years. In the first decade, it was kind of like a Wild West of pharmaceutical sales tactics. Pharmaceutical ads were starting to air on TV. A good friend of mine who is a pharma rep broke it down for me: They would find out what the doctor wanted and they would show up with whatever that was. He was waiting for the doctor, a chain-smoking doctor in Bland, Virginia, and another rep has already beaten him — they were there with a carton of cigarettes with a Celexa sticker on it.
Purdue used similar techniques. They paid doctors to be spokesmen for them, saying: Come to a seminar in Boca Raton or Arizona, and we’ll pay you to go out and give speeches about [OxyContin].
Many people who become addicted to OxyContin eventually move on to heroin, which is cheaper. How are we doing with the pill problem? And even if we have tackled that issue, isn’t it a bigger problem once people start taking heroin?
The updated CDC guidelines in 2016 were a great improvement. It was kind of what those parents who initially lost their kids to OxyContin overdose wanted. They wanted the guideline to be that opioids were used sparingly, that doctors try pain relievers like ibuprofen and aspirin before prescribing the highly addictive pills, and that they give most patients only a few days’ supply — that opioid therapy for short-term pain last three days, and very rarely longer than seven. Overall, that’s good, but as soon as the OxyContin and the other pills got harder to get, you saw the drug cartels bringing in heroin.
Marijuana laws started becoming legal in states, and the drug cartels needed to make up their profit [from lost marijuana sales]. The doctors are doing better about not prescribing opioids out the wazoo, but we now have 2.6 million Americans with opioid use disorder. What are we going to do about that? You just can’t flip off a switch and it stops.
What I see on the ground are serious holes in the tapestry of treatment. The Roanoke Times finally did a story on medication-assisted treatment, or MAT, which combines therapy with medications like methadone or Suboxone. In it, they quote Steve Ratliff, adult and family services director for Blue Ridge Behavioral Healthcare, and he doesn’t believe in it. He told the newspaper that they only use buprenorphine if counseling has been attempted first and doesn’t work — and then they give them the option. This is not consistent with state policy, and in my view, it is just wrong.
Now, in an age of Fentanyl — dealers started cutting heroin with fentanyl heavily in 2015, and it became much stronger and deadlier — the risk of dying is much higher. We’re going to let them fail first?
In the book, you point to evidence that shows that abstinence-based centers, a model of treatment in which people are cut completely off of the drugs, have not proven to be the best route to recovery. So why do they dominate the treatment landscape?
I think it’s because the recovery industry developed largely as treatment centers for alcoholism. So the abstinence-only models put forth by [Alcoholics Anonymous and Narcotics Anonymous] are historically what most of the recovery industry has been centered around.
Abstinence models may be better to treat alcoholism, but not opioids, since opioids, especially those laced with fentanyl, are deadly. [Many fewer people] OD on alcohol [compared to heroin]. What I see on the ground is families that can afford to send their children to rehabs — and most families can’t — end up spending thousands of dollars for treatment that is not what science says is the best way to treat opioid use disorder.
One family I know with two heroin-addicted sons spent $300,000 on an abstinence center. That wasn’t including the heroin-related legal fees that they had.
More than 40,000 Americans died of overdoses from opioids such as fentanyl, heroin, and prescribed painkillers in 2016, and they are estimating even more in 2017. What about long-term consequences? If this has been going on for 20 years, what will the country look like in 20 more years?
Think about the foster care system. In Lee County, one in three kids are raised in foster care now. And think about what are their kids going to be like? That’s really frightening.
Another long-term consequence that scares the dickens out of me is hepatitis C. There are centers, needle exchange programs, where you come and you turn in your dirty needles. There, you get clean needles and you get to know these people who want to help you and want to help you get you hooked up with social work and counseling and ultimately, when you’re ready, go on to treatment. That’s what’s missing in most of America right now.
I was visiting a needle exchange recovery program in Las Vegas recently that was only located on the outskirts of town. If you’re an addicted person and you’re homeless, you probably live near the downtown in these tunnels underneath the city, so the homeless people who are addicted have to save up their bus fare to go there. And it’s because they didn’t want the tourists to see the addicts.
The guy who runs it who has been in this world of prevention and harm reduction for a long time said that what keeps him up at night is in 15 to 20 years, we’re gonna have a tsunami of hepatitis C because so many people who are injecting are sharing needles.
I mean, it’s cultural. Our country’s way of thinking has been, “We gotta incarcerate our way out of this,” “We gotta be tough,” “We gotta just say no.” And that has not worked in other countries. Other countries that have adopted a treatment approach have done much better.
This topic has finally become of part of a national conversation — but what’s still missing from the larger dialogue? What surprised you after spending all this time with addicts, dealers, and families?
What surprised me is how this could happen to just anyone. It literally spares no one. And because it started out in these politically unimportant places, people didn’t pay attention to it. We’re basically leaving the institution of the family to deal with the worst drug crisis in the nation’s history.
You see these families in so much pain. They’re so weary; they’re so worn out. Many of them have these ideological divides within the family, because maybe they have somebody in AA or NA themselves — who maybe doesn’t see medication-assisted treatment as the best way for their addicted loved one to get better.
You see that colors a lot of family dynamics around medication-assisted treatment, and you see them worn out also because of bad behavior by the addicted people whose brains have been taken over by this drug, such as users who steal from their families to fund their next fix, for instance. Too often, the addicted person isn’t seen as someone worthy of evidence-based medical care until people are sitting in the pews at their funeral.
I want to know how the book affected you, especially since a lot of the reporting was done in your own community. In particular, one of the women addicted to heroin who you spent a lot of time with ended up becoming a prostitute in Nevada, and was eventually found dead, in what appeared to be a violent murder.
It was really hard to interview people who died before I had the chance to write up my book, but it was nothing compared to the pain that these families are going through.
I was constantly balancing that between anxiety and feeling hopeless about it.
I take things pretty personally sometimes. I have hundreds of text messages back and forth with many of the mothers in the book. But as a friend of mine said, “The only way I think you’re going to be able to protect yourself and write this book at the same time and survive it is to find the helpers.”
Correction: A pervious version of this article misstated the number of opioid overdoses in the past 15 years.
Hope Reese is a journalist in Louisville, Kentucky. Her writing has appeared in the Atlantic, the Boston Globe, the Chicago Tribune, Playboy, Vox, and other publications. Find her on Twitter @hope_reese.