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Beth Macy takes us into the heart of America’s struggle with opioid addiction. From distressed small communities in Central Appalachia to wealthy suburbs and once-idyllic farm towns, this powerful and moving story illustrates how a national crisis became so firmly entrenched.
At the heart of the narrative is a large corporation, Purdue – whose owners are celebrated for their sponsorship of art galleries and museums – that targeted areas of the country already awash in painkillers and encouraged small town doctors to prescribe OxyContin, a highly addictive drug. Evidence of its capacity to enslave its users was suppressed. Macy tries to answer a grieving mother’s question – why her only son died – and comes away with a harrowing story of greed and need.
Overtreatment with painkillers became the norm. In distressed communities of ex-miners and factory workers, the unemployed used painkillers both to numb the pain of joblessness and pay their bills. Macy’s portraits of the families, cops and doctors struggling to ameliorate this epidemic are unforgettable. But in a country unable to provide basic healthcare for all, Macy still finds reason to hope that there may be a decent future for people so abandoned by their political leaders. This is an essential book for anyone trying to understand the harrowing realities of Trump’s America.
Welcome Page
About Dopesick
Epigraph
Dedication
Author’s Note
Prologue
Part One: The People v. Purdue
Chapter One: The United States of Amnesia
Chapter Two: Swag ’n’ Dash
Chapter Three: Message Board Memorial
Chapter Four: “The Corporation Feels No Pain”
Part Two: Objects in Mirror Are Closer Than They Appear
Chapter Five: Suburban Sprawl
Chapter Six: “Like Shooting Jesus”
Chapter Seven: FUBI
Chapter Eight: “Shit Don’t Stop”
Part Three: “A Broken System”
Chapter Nine: Whac-A-Mole
Chapter Ten: Liminality
Chapter Eleven: Hope on a Spreadsheet
Chapter Twelve: “Brother, Wrong or Right”
Chapter Thirteen: Outcasts and Inroads
Epilogue: Soldier’s Disease
Plate Section
Acknowledgments
Notes
Index
About Beth Macy
An Invitation from the Publisher
Copyright
This evil is confined to no class or occupation. It numbers among its victims some of the best women and men of all classes. Prompt action is then demanded, lest our land should become…stupefied by the direful effects of narcotics and thus diseased physically, mentally, and morally, the love of liberty swallowed up by the love of opium, whilst the masses of our people would become fit subjects for a despot.
—Dr. W. G. Rogers, writing in The Daily Dispatch (Richmond, VA), January 25, 1884
A mother’s love for her child is like nothing else in the world. It knows no law, no pity, it dares all things and crushes down remorselessly all that stands in its path.
—Agatha Christie, “The Last Séance” (from The Hound of Death and Other Stories)
In memory of Scott Roth (1988–2010), Jesse Bolstridge (1994–2013), Colton Scott Banks (1993–2012), Brandon Robert Perullo (1983–2014), John Robert “Bobby” Baylis (1986–2015), Jordan “Joey” Gilbert (1989–2017), Randy Nuss (1984–2003), Arnold Fayne McCauley (1934–2009), Patrick Michael Stewart (1980–2004), Eddie Bisch (1982–2001), Jessee Creed Baker (1982–2017), and Theresa Helen Henry (1989–2017)
In 2012, I began reporting on the heroin epidemic as it landed in the suburbs of Roanoke, Virginia, where I had covered marginalized families for the Roanoke Times for two decades, predominantly those based in the inner city. When I first wrote about heroin in the suburbs, most families I interviewed were too ashamed to go on the record.
Five years later as I finished writing this book, nearly everyone agreed for their names to be used, with the exception of a few, as noted in the text, who feared going public would jeopardize their jobs or their safety.
I’m indebted to the families I first met in 2012 who allowed me to continue following their stories as their loved ones grappled with rehab and prison, with recovery and relapse. I’m also grateful for insights gleaned from several rural Virginia families, advocates, and first responders, many of whom were quietly battling the scourge almost two decades before I appeared on the scene. Several law enforcement officials spoke with me on background and on the record, including a few who had arrested their own relatives for peddling dope. So did scores of doctors and other caregivers who, after working fourteen-plus-hour days, did not feel their work was complete without getting the story of this epidemic out there.
A few interviewees died before I had time to transcribe my notes, including one by his own hand after relapsing and fearing that his wife—whom he loved more than anything in the world—would divorce him. “If she ever figures out she don’t need me,” he confided, “I’m screwed.”
Their survivors continued talking to me during their most fragile moments, generously texting and calling and emailing photographs long after their loved ones’ battles were over. One requested my MP3 recording of her departed loved one’s interview, so desperate was she to hear his voice again. Another shared her deceased daughter’s journals.
I’m particularly indebted to four Virginia moms: Kristi Fernandez, Ginger Mumpower, Jamie Waldrop, and Patricia Mehrmann. More than anyone, they helped me understand the crushing and sometimes contradictory facets of an inadequate criminal justice system often working at cross-purposes against medical science, and a health care bureaucracy that continues pumping out hard-core pain pills in large doses while seeking to quell cravings and turn around lives with yet more medication.
In sharing their experiences, these mothers hoped readers would be moved to advocate for life-saving addiction treatment and research, health care and criminal justice reform, and for political leadership capable of steering America out of the worst drug epidemic in modern history. Until then, they hoped their children’s stories would illuminate the need for patients not only to become more discerning consumers of health care but also to employ a healthy skepticism the next time a pharmaceutical company announces its latest wonder drug.
Riverview Cemetery, Strasburg, Virginia
Two years into a twenty-three-year prison sentence, on a day pushing 100 degrees, Ronnie Jones had his first visitor. I’d spent almost a year listening to police and prosecutors describe Jones, imprisoned for armed heroin distribution, as a predator. After three months of requests, I walked along the manicured entranceway of Hazelton Federal Correctional Institution on the outskirts of Bruceton Mills, West Virginia. The air was so thick that the flags framing the concrete-block structure hung there drooping, as still as the razor wire that scalloped the roofs.
In the state’s northeastern crook, bordering Pennsylvania to the north and Maryland to the east, Preston County had once been dominated by strip-mining. But by the mid-2000s, most of the mines had shut down, and the prison had taken over as the county’s largest employer, with eight hundred guards and staff.
My August 2016 interview had taken several weeks to arrange with the Bureau of Prisons pecking order in Washington, D.C., but first I had to navigate weeks of curt back-and-forth with Jones, over the prison’s monitored email, to get his OK. “Exactly who have you spoken to as of today that was involved with my case?” he wanted to know. What personal information about him did I intend to use?
Jones agreed to let me visit, finally, because he wanted his daughters, in kindergarten and first grade when their dad was arrested in June 2013, to understand “there’s a different side of me,” as he put it. The last they’d seen him, a week before his arrest, he had delivered birthday cupcakes to their school.
I thought of the “tsunami of misery” Jones had first unleashed in Woodstock, Virginia, as his prosecutor put it, before it fanned out in waves over the northwestern region of the state and into some of Washington’s western bedroom communities in 2012 and 2013. In just a few months’ time, Jones was presiding over the largest heroin ring in the region, transforming a handful of users into hundreds.
As I made my way to the prison, I calculated the human toll, the hundreds of addicted people who ended up dopesick when their heroin supply was suddenly cut by Jones’s arrest: throwing up and sweating and shitting their pants. When Jones was jailed in 2013, many of the newly addicted Woodstock users began carpooling to the nearest big cities—Baltimore, Washington, and even Martinsburg, West Virginia, aka Little Baltimore—to score drugs, converging on known heroin hot spots and playing drug-dealer Russian roulette.
I didn’t yet know that a single batch of heroin was about to land in Huntington, West Virginia, four hours west of Jones’s cell, that would halt the breathing of twenty-six people in a single day, before the week was out. Those overdoses were fueled by the latest synthetic opioid, carfentanil, imported from China with a stroke on a computer keyboard. Carfentanil is an elephant sedative one hundred times stronger than fentanyl, which is twenty-five to fifty times stronger than heroin. For the fifth year in a row, the state of West Virginia’s indigent burial-assistance program was about to exhaust its funds from interring opioid-overdose victims.
Similar surges were happening across the country, from Florida to Sacramento to Barre, Vermont. Every person I interviewed that summer, from treatment providers to parents of the addicted to the judges who were sending the addicted to prison or jail, was growing more burdened by the day. The enormity of America’s drug problem was finally dawning on them and on the rest of us—two decades after the opioid epidemic first took root. (Although the word “opiate” historically refers to drugs derived from the opium poppy and “opioid” to chemical versions, the now more widely accepted term “opioid” is used in this book for both forms of painkillers.)
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 fifty, killing more people than guns or car accidents, at a rate higher than the HIV epidemic at its peak.
The rate of casualties is so unprecedented that it’s almost impossible to look at the total number dead—and at the doctors and mothers and teachers and foster parents who survive them—and not wonder why the nation’s response has been so slow in coming and so impotently executed when it finally did.
Ronnie Jones had run one of the largest drug rings in the mid-Atlantic United States, a region with some of the highest overdose rates in the nation. But I wasn’t driving to West Virginia for epidemiological insights or even a narrative of redemption from Jones.
I’d been dispatched to prison by a specific grieving mother, clutching a portrait of her nineteen-year-old son. I wanted to understand the death of Jesse Bolstridge, a robust high school football player barely old enough to grow a patchy beard on his chin.
What exactly, his mother wanted to know, had led to the death of her only son?
I’d been trying to address that same question for more than five years, in one form or another, for several mothers I knew. But now I had someone I could ask.
*
Three months before visiting Jones, in the spring of 2016, Kristi Fernandez and I stood next to Jesse’s grave on a rolling hillside in Strasburg, Virginia, in the shadow of Signal Knob. She’d asked me to meet her at one of her regular cemetery stops, on her way home from work, so I could see how she’d positioned his marker, just so, at the edge of the graveyard.
It was possible to stand at Jesse’s headstone—emblazoned with the foot-high number 55, in the same font as the lettering on his Strasburg Rams varsity jersey—and look down on the stadium where he had once summoned the crowd to its feet simply by running onto the field and pumping his arms.
In a small town where football is as central to identity as the nearby Civil War battlefields dotting the foothills of the Blue Ridge, Jesse loved nothing more than making the hometown crowd roar.
He had always craved movement, the choke on his internal engine revving long after his peers had mastered their own. As a toddler, he staunchly refused to nap, succumbing to sleep on the floor midplay, an action figure in one hand and a toy car in the other. This restlessness was part of the epidemic’s story, too, I would later learn. So were the drugs Jesse’s high school buddies pilfered from their parents’ and grandparents’ medicine cabinets—the kind of leftovers that pile up after knee-replacement surgery or a blown back.
Jesse had been a ladies’ man, the boy next door, a jokester who began most of his sentences with the word “Dude.” When he left his house on foot, the neighbors did a double take, marveling at the trail of cats shadowing him as he walked.
Kristi pointed out the cat’s paw she had engraved at the base of Jesse’s headstone, right next to the phrase miss you more, a family shorthand they had the habit of using whenever they talked by phone.
“I miss you,” she’d say.
“Miss you more,” he’d tell her.
“Miss you more,” she’d answer. And on and on.
Kristi takes pride in the way the family maintains Jesse’s grave, switching out the holiday decorations, adding kitschy trinkets, wiping away the rain-splashed mud. “It’s the brightest one here,” his younger twin sisters like to say as they sweep away the errant grass clippings.
When I pulled into the cemetery for our first meeting, Kristi had taken it as an omen that my license plate included Jesse’s number, 55. She’s always looking for signs from Jesse—a glint of sun shining through the clouds, a Mother’s Day brunch receipt for $64.55. To her, my license plate number meant our meeting was Jesse-sanctioned and Jesse-approved.
Kristi used to think that maintaining Jesse’s grave was “the last thing we can do for him,” she told me, choking back tears. But right now she’s obsessed with the story of her son’s swift descent into addiction—the missing details that might explain how Jesse went from being a high school football hunk and burly construction worker to a heroin-overdose statistic, slumped on someone else’s bathroom floor. If she understood the progression of his addiction better, she reasons, maybe she could help other parents protect their kids from stumbling down that same path.
“I just want to be able to say, ‘This is what happened to Jesse,’ so I can be educated, so I can help others,” Kristi says. “But in my mind, the story doesn’t add up, and it drives me crazy.”
Maybe a mother’s questions about a child’s death can never be totally answered, and yet Kristi’s pain sits there between us, no less urgent today than it felt on the day he died. To comprehend how she was left with these questions—and how our country came to this moment—I needed to widen the scope of my investigation both in geography and in time. I would fold in questions from other mothers, too, who wanted to understand why their addicted sons were imprisoned now instead of in treatment; why their addicted daughters were still out on the streets, God only knew where.
*
When a new drug sweeps the country, it historically starts in the big cities and gradually spreads to the hinterlands, as in the cases of cocaine and crack. But the opioid epidemic began in exactly the opposite manner, grabbing a toehold in isolated Appalachia, Midwestern rust belt counties, and rural Maine. Working-class families who were traditionally dependent on jobs in high-risk industries to pay their bills—coal mining in southwest Virginia, steel milling in western Pennsylvania, logging in Maine—weren’t just the first to experience the epidemic of drug overdose; they also happened to live in politically unimportant places, hollows and towns and fishing villages where the treatment options were likely to be hours from home.
Jesse Bolstridge was born in the mid-1990s, when opioid addiction first took root. His short life represents the arc of the epidemic’s toll, the apex of which is nowhere close to being reached.
If I could retrace the epidemic as it shape-shifted across the spine of the Appalachians, roughly paralleling Interstate 81 as it fanned out from the coalfields and crept north up the Shenandoah Valley, I could understand how prescription pill and heroin abuse was allowed to fester, moving quietly and stealthily across this country, cloaked in stigma and shame.
Set in three culturally distinct communities that represent the evolution of the epidemic as I reported it, Dopesick begins in the coalfields, in the hamlet of St. Charles, Virginia, in the remote westernmost corner of the state, largely with the introduction of the painkiller OxyContin in 1996.
From there, the scourge not only advanced into new territories but also arrived via a different delivery system, as the morphine molecule shifted from OxyContin and other painkillers like Vicodin and Percocet to heroin, the pills’ illicit twin, and, later, even stronger synthetic analogs.
As the epidemic gained strength, it sent out new geographic shoots, moving from predominantly rural areas to urban and suburban settings, though the pattern was never stable or fixed. Heroin landed in the suburbs and cookie-cutter subdivisions near my home in Roanoke in the mid-2000s. But it wasn’t widely acknowledged until a prominent jeweler and civic leader, Ginger Mumpower, drove her addicted son to the federal prison where he would spend the next five years, for his role in a former classmate’s overdose death.
I covered Spencer Mumpower’s transition from private-school student to federal inmate at the same time I witnessed the rise in overdose deaths spread north along I-81 from Roanoke. It infected pristine farm pastures and small northern Shenandoah Valley towns, as more users, and increasingly vigilant medical and criminal justice systems, propelled the addicted onto the urban corridor from Baltimore to New York. If you live in a city, maybe you’ve seen the public restroom with a sharps container, or witnessed a librarian administer Narcan.
While more and more Americans die of drug overdose, it is impossible to not look back at the early days of what we now recognize as an epidemic and wonder what might have been done to slow or stop it. Kristi Fernandez’s questions are not hers alone. Until we understand how we reached this place, America will remain a country where getting addicted is far easier than securing treatment.
*
The worst drug epidemic in American history didn’t land in the bucolic northern Shenandoah Valley until 2012, when Ronnie Jones, a twice-convicted drug dealer from the Washington suburbs, arrived in the back of a Virginia Department of Corrections van and set about turning a handful of football players, tree trimmers, and farmers’ kids who used pills recreationally into hundreds of heroin addicts, as police officers told the story.
The transition here, in the quiet town of Woodstock, was driven by the same twisted math I’d witnessed elsewhere, as many users began with prescriptions, then resorted to buying heroin from dealers and selling portions of their supply to fuel their next purchase. Because the most important thing for the morphine-hijacked brain is, always, not to experience the crushing physical and psychological pain of withdrawal: to avoid dopesickness at any cost.
To feed their addictions, many users recruit new customers. Who eventually recruit new customers. And the exponential growth continues until the cycle too often ends in jail or prison or worse—in a premature grave like Jesse’s adorned with teddy bears, R2-D2 action figures, and the parting words of mothers like Kristi engraved in granite: until i take my final breath, you will live in my heart.
*
To reach Ronnie Jones, I head north on the nearest “heroin highway,” I-81. I travel roughly the same path in my car, only in reverse, that Jones’s drugs did by bus, his heroin camouflaged inside Pringle’s cans and plastic Walmart bags on the floor beside him or his hired drug runners.
On the suburban outskirts of Roanoke, I drive near the upper-middle-class subdivision of Hidden Valley, where a young woman I’ve been following for a year named Tess Henry was once a straight-A student and basketball star. At the moment, she’s AWOL—her mother and I have no idea where she is—although sometimes we catch glimpses of her on our cellphones: a Facebook exchange between Tess and one of her heroin dealers, or a prostitution ad through which Tess will fund her next fix.
I pass Ginger’s Jewelry, the high-end store where parents of the addicted still drive from two hours away simply because they can think of nowhere else to turn. They’ve read about Ginger’s imprisoned son in the newspaper, and they want to ask her how to handle the pitfalls of raising an addicted child.
Up the Shenandoah Valley on the interstate, I pass New Market and think not of the men who fought in the famous 1864 Civil War battle but of the women who grew poppies for the benefit of wounded soldiers, harvesting morphine from the dried juice inside the seed pods. Three decades later, the German elixir peddlers at Bayer Laboratories would stock America’s drugstores with a brand-new version of that same molecule, a pill marketed as both a cough remedy and a cure for the nation’s soaring morphine epidemic, known as “morphinism,” or soldier’s disease. Its label looked like an amusement advertisement you might have seen on a circus poster, a word derived from the German for “heroic” and bracketed by a swirling ribbon frame: heroin. It was sold widely from drugstore counters, no prescription necessary, not only for veterans but also for women with menstrual cramps and babies with hiccups.
Outside Woodstock, I pass George’s Chicken, the poultry-processing plant where Ronnie Jones first arrived to work in a Department of Corrections work-release program, clad in prison-issue khakis. I pass the house nearby where a cop I know spent days, nights, and weekends crouched under a bedroom window, surveilling Jones and his co-workers from behind binoculars—a fraction of the man-hours the government invested in putting members of Jones’s heroin ring behind bars.
I head northwest toward West Virginia, the crumbling landscape like so many of the distressed towns I’ve already traversed in Virginia some four hundred miles south, down to the same hillary for prison signs and the same Confederate flags waving presciently from their posts.
At the prison, I park my car and walk through the heavy front door. A handler named Rachel ushers me through security, making cheerful small talk as we head deeper inside the concrete maze and through three different sets of locked doors, her massive cluster of keys reverberating like chimes at each checkpoint.
We pass through a recreation area, where several men—all but one of the prisoners black and brown, I can’t help noticing—push mops and brooms around the cavernous room, looking up and nodding as we pass. The manufactured air inside is cold, and it smells of Clorox.
Ronnie Jones is already waiting for me on the other side of the last locked door, seated at a table. He looks thinner and older than he did in his mug shot, his prison khakis baggy, his trim Afro and beard flecked with gray. He looks tired, and the whites of his eyes are tinged with red.
He rises from the chair to shake my hand, then sits back down, his hands folded into a steeple, his elbows resting on the table between us. His mood is unreadable.
The glassed-in room is beige, the floors are beige, and so is Rachel, in her beige-and-blue uniform and no-nonsense shoes, the kind you could run in if you had to. She tells us to knock on the window if we need her, then leaves for her perch in the rec room, on the other side of the window, the door lock clicking decisively behind her.
I open my notebook, situate the questions I’ve prepared off to the side, next to my spare pens. I’m thinking of Kristi and Ginger and of Tess’s mom, and what Jones might say that will explain the fate of these mothers’ kids.
Jones leans forward, expectant and unsmiling, and rubs his hands together, as if we’re business associates sitting down to hammer out a deal.
Then he takes a deep breath and, relaxing back into his chair, he waits for me to start.
Pennington Gap, Lee County, Virginia
Former coal-mining facility, Lee County, Virginia
Though the opioid epidemic would go on to spare no segment of America, nowhere has it settled in and extracted as steep a toll as in the depressed former mill and mining communities of central Appalachia, where the desperate and jobless rip copper wire out of abandoned factories to resell on the black market and jimmy large-screen TVs through a Walmart garden-center fence crack to keep from “fiending for dope.”
In a region where few businesses dare to set up shop because it’s hard to find workers who can pass a drug test, young parents can die of heroin overdose one day, leaving their untended baby to succumb to dehydration and starvation three days later.
Appalachia was among the first places where the malaise of opioid pills hit the nation in the mid-1990s, ensnaring coal miners, loggers, furniture makers, and their kids. Two decades after the epidemic erupted, Princeton researchers Anne Case and Angus Deaton were the first economists to sound the alarm. Their bombshell analysis in December 2015 showed that mortality rates among white Americans had quietly risen a half-percent annually between the years 1999 and 2013 while midlife mortality continued to fall in other affluent countries. “Half a million people are dead who should not be dead,” Deaton told the Washington Post, blaming the surge on suicides, alcohol-related liver disease, and drug poisonings—predominantly opioids—which the economists later referred to as “diseases of despair.” While the data from which Case and Deaton draw is not restricted to deaths by drug overdose, their central finding of “a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women” demonstrates that the opioid epidemic rests inside a host of other diseases of despair statistically significant enough to reverse “decades of progress in mortality.”
At roughly the same time the Case and Deaton study was published, a Kaiser Family Foundation poll showed that 56 percent of Americans now knew someone who abused, was addicted to, or died from an overdose of opioids. Nationwide, the difference in life expectancy between the poorest fifth of Americans by income and the richest fifth widened from 1980 to 2010 by thirteen years. For a long time, it was assumed that the core driver of this differential was access to health care and other protective benefits of relative wealth. But in Appalachia, those disparities are even starker, with overdose mortality rates 65 percent higher than in the rest of the nation. Clearly, the problem wasn’t just of some people dying sooner; it was of white Americans dying in their prime.
The story of how the opioid epidemic came to change this country begins in the mid to late 1990s, in Virginia’s westernmost point, in the pie-shaped county sandwiched between Tennessee and Kentucky, a place closer to eight other state capitals than its own, in Richmond. Head north as the crow flies from the county seat of Jonesville and you’ll end up west of Detroit.
Geopolitically, Lee County was the ultimate flyover region, hard to access by car, full of curvy, two-lane roads, and dotted with rusted-out coal tipples. It was the precise point in America where politicians were least likely to hold campaign rallies or pretend to give a shit—until the unchecked epidemic finally landed on their couches, too.
Four hundred miles away, at the northern end of the Shenandoah Valley, a stressed-out preschool teacher would tell Kristi Fernandez around this time that her four-year-old son, Jesse, was too rambunctious for his own good. He was causing mayhem in the classroom, so Kristi took him to his pediatrician, who urged her to put him on Ritalin. She acquiesced two years later, the drug seemed to quell his jitters and anxiety, and the teacher complaints stopped.
But he was still her high-energy Jesse. You could tell he was hyper even by the way he signed his name, blocking the letters out joyfully and haphazardly, adding a stick-figure drawing of the sun with a smiley face below the first E. The sun’s rays stuck out helter-skelter, like a country boy’s cowlick, as if it were running and winking at you all at once.
*
Lieutenant Richard Stallard was making his usual rounds, patrolling through Bullitt Park in Big Stone Gap in Wise County near the Lee County line. This was the same iconic small town romanticized in Adriana Trigiani’s novel and film Big Stone Gap, the one based on her idyllic upbringing in the 1970s, when a self-described town spinster with the good looks of Ashley Judd could spend her days wandering western Virginia’s hills and hollows, delivering prescriptions for her family-run pharmacy without a thought of danger.
The year was 1997, a pivotal moment in the history of opioid addiction, and Stallard was about to sound the first muffled alarm. Across central Appalachia’s coal country, people hadn’t yet begun locking their toolsheds and barn doors as a guard against those addicted to OxyContin, looking for anything to steal to fund their next fix.
The region was still referred to as the coalfields, even though coal-mining jobs had long been in steep decline. It had been three decades since President Lyndon Johnson squatted on the porch of a ramshackle house just a few counties west, having a chat with an unemployed sawmiller that led him to launch his War on Poverty, which resulted in bedrock social programs like food stamps, Medicaid, Medicare, and Head Start. But poverty remained very much with the coalfields the day Stallard had his first brush with a new and powerful painkiller. Whereas half the region lived in poverty in 1964 and hunger abounded, it now held national records for obesity, disability rates, and drug diversion, the practice of using and/or selling prescriptions for nonmedical purposes.
If fat was the new skinny, pills were becoming the new coal.
Stallard was sitting in his patrol car in the middle of the day when a familiar face appeared. An informant he’d been working with for years had some fresh intel. At the time, the area’s most commonly diverted opioids were Lortab and Percocet, both of which sold on the streets for $10 a pill. Up until now, the most expensive painkiller of the bunch had been Dilaudid, the brand name for hydromorphone, a morphine derivative that sold on the black market for $40.
The informant leaned into Stallard’s cruiser. “This feller up here’s got this new stuff he’s selling. It’s called Oxy, and he says it’s great,” he said.
“What is it again?” Stallard asked.
“It’s Oxy-compton…something like that.”
Pill users were already misusing it to intensify their high, the informant explained, as well as selling it on the black market. Oxy came in much higher dosages than standard painkillers, and an 80-milligram tablet sold for $80, making its potential for black-market sales much higher than that of Dilaudid and Lortab. The increased potency made the drug a cash cow for the company that manufactured it, too.
The informant had more specifics: Users had already figured out an end run around the pill’s time-release mechanism, a coating stamped with oc and the milligram dosage. They simply popped a tablet in their mouths for a minute or two, until the rubberized coating melted away, then rubbed it off on their shirts. Forty-milligram Oxys left an orange sheen on their shirtsleeves, the 80-milligrams a tinge of green. The remaining tiny pearl of pure oxycodone could be crushed, then snorted or mixed with water and injected.
The euphoria was immediate and intense, with a purity similar to that of heroin. Stallard wondered what was coming next. In the early nineties, Colombian cartels had increased the potency of the heroin they were selling in urban markets to increase their market share—the goal being to attract needle-phobic users who preferred snorting over injecting. But as tolerance to the stronger heroin increased, the snorters overcame their aversion to needles and soon became IV heroin users.
As soon as Stallard got back to the station, he picked up the phone.
The town pharmacist on the other line was incredulous: “Man, we only just got it a month or two ago. And you’re telling me it’s already on the street?”
The pharmacist had read the FDA-approved package insert for OxyContin. Most pain pills lasted only four hours, but OxyContin was supposed to provide steady relief three times as long, giving people in serious pain the miracle of uninterrupted sleep. In an early concession to the potential for its abuse, the makers of OxyContin claimed the slow-release delivery mechanism would frustrate drug abusers chasing a euphoric rush.
Based on Stallard’s news, the pharmacist already doubted the company’s claims: “Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.” If the town’s most experienced drug detective was calling him about it just a couple of months after the drug’s release, and if his neighbors were already walking around with their shirts stained orange and green, it was definitely being abused.
*
Approved by the Food and Drug Administration in late 1995, OxyContin was the brainchild of a little-known, family-owned pharmaceutical company called Purdue Frederick, based in Stamford, Connecticut. The company was virtually unheard of when a trio of research psychiatrists and brothers—Mortimer, Raymond, and Arthur Sackler—bought it from its original Manhattan-based owners in 1952, with only a few employees and annual sales of just $20,000. The new owners made their initial fortunes specializing in such over-the-counter products as laxatives, earwax remover, and the antiseptic Betadine, used to wash down the Apollo 11 spacecraft after its historic mission to the moon. Expanding internationally in the 1970s, the Sacklers acquired Scottish and British drug companies and paved the way for their entry into the pain-relief business with the development of an end-of-life painkiller derived from morphine, MS Contin, in 1984. (Contin was an abbreviation of “continuous.”) With annual sales of $170 million, MS Contin had run its profit-making course by the mid-1990s.
As its patent was set to expire, the company launched OxyContin to fill the void, with the intention of marketing the new drug, a reformulation of the painkiller oxycodone, beyond hospice and end-of-life care. It was a tweak of a compound first developed in 1917, a form of oxycodone synthesized from thebaine, an ingredient in the Persian poppy.
Famously private, the brothers were better known for their philanthropy than for their drug-developing prowess, counting among their friends British royalty, Nobel Prize winners, and executives of the many Sackler-named art wings from the Smithsonian to the Metropolitan Museum of Art.
Promotion and sales were managed by the company’s marketing arm, Purdue Pharma, launched in the nation’s best-known corporate tax haven—Delaware.
Purdue Pharma touted the safety of its new opioid-delivery system everywhere its merchants went. “If you take the medicine like it is prescribed, the risk of addiction when taking an opioid is one-half of 1 percent,” said Dr. J. David Haddox, a pain specialist who became the company’s point man for the drug. Iatrogenic (or doctor-caused) addiction, in the words of a 1996 company training session for doctors, was not just unusual; it was “exquisitely rare.”
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In the United States of Amnesia, as Gore Vidal once called it, there were people in history who might have expressed some skepticism about Haddox’s claim, had anyone bothered reading up on them. Ever since Neolithic humans figured out that the juice nestled inside the head of a poppy could be dried, dehydrated, and smoked for the purposes of getting high or getting well, depending on your point of view, opium had inspired all manner of commerce and conflict. The British and Chinese fought two nineteenth-century wars over it. And opium was a chief ingredient in laudanum, the alcohol-laced tincture used to treat everything from yellow fever and cholera to headaches and general pain. In 1804, at the end of Alexander Hamilton’s ill-fated duel, doctors gave him laudanum to numb the agony caused by the bullet that pierced his liver, then lodged in his vertebrae.
In the 1820s, one of Boston’s leading merchants masterminded an opium-smuggling operation off the Cantonese coast, spawning millions for Boston Brahmins with the names of Cabot, Delano (as in FDR), and Forbes. This money would go on to build many of the nation’s first railroads, mines, and factories.
Around that time, a twenty-one-year-old German apothecary urged caution when he published the first major opium breakthrough. Friedrich Sertürner had isolated the active ingredient inside the poppy, an alkaloid he named morphium after the Greek god of dreams, Morpheus. Sertürner quickly understood that morphine was exponentially more powerful than processed opium, noting that its side effects often progressed from euphoria to depression and nausea. He had not at all liked what the compound did to his dogs: It made them pass out drooling, only to awaken in an edgy and aggressive state, with fevers and diarrhea—the same state of withdrawal the opium-addicted in China had long referred to as “yen.” (What modern-day addicted users call dopesick or fiending, William S. Burroughs referred to as junk sick, gaping, or yenning.) “I consider it my duty to attract attention to the terrible effects of this new substance in order that calamity may be averted,” Sertürner wrote, prophetically, in 1810.
But his medical descendants were not so conscientious. Dr. Alexander Wood, the Scottish inventor of the hypodermic needle, hailed his 1853 creation by swearing that, whereas smoking or swallowing morphine caused addiction, shooting it up would not. No one mentioned Sertürner’s warning decades before. It was easier to be swayed by Wood’s shiny new thing.
So when doctors departed from the homes of the injured Civil War veterans they were treating, it became standard practice to leave behind both morphine and hypodermic needles, with instructions to use as needed. An estimated hundred thousand veterans became addicted, many identifiable not by shirt smudges of orange and green but by the leather bags they carried, containing needles and morphine tablets, dangling from cords around their neck. The addiction was particularly severe among white Southerners in small cities and towns, where heartbroken wives, fathers, and mothers turned to drugs to cope with devastating war fatalities and the economic uncertainty brought on by slavery’s end.
“Since the close of the war, men once wealthy, but impoverished by the rebellion, have taken to eating and drinking opium to drown their sorrows,” lamented an opium dealer in New York.
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By the 1870s, injecting morphine was so popular among the upper classes in Europe and the United States that doctors used it for a variety of ailments, from menstrual pain to inflammation of the eyes. The almost total lack of regulatory oversight created a kind of Wild West for patent medicines, with morphine and opium pills available at the nearest drugstore counter, no prescription necessary. As long as a doctor initially OK’d the practice, even injected morphine was utterly accepted. Daily users were not socially stigmatized, because reliance on the drug was iatrogenic.
Morphine did generate public debate, if tepid, from a few alarm-sounding doctors. In 1884, the Virginia General Assembly considered placing regulations on over-the-counter versions of opium and morphine, a move the local newspaper denounced as “class legislation.” In response, Richmond doctor W. G. Rogers wrote an empathetic, impassioned letter urging the newspaper to reconsider its stance:
I know persons who have been opium-eaters for some years who now daily consume enough of this poison in the form of morphine to kill a half dozen robust men not used to the poison. I have heard them, with tears in their eyes, say that they wished it had never been prescribed for them, and…many of them [have] inserted into the flesh frequently during each day, in spite of the painful abscesses it often causes, until in some instances the whole surface of the body seems to be tattooed. I have heard one exclaim with sorrow that there was no longer a place to put it. Whilst they know it is killing them, more or less rapidly, the fascination and power of the drug [are] irresistible, and it is a rare exception if they ever cease to take it as long as it can be obtained until they have poisoned themselves to death.
Should not this, then, be prevented, though the profits of [the drug-sellers] be diminished?
The legislature declined to approve the bill, considering it government overreach, which allowed the tentacles of morphinism to dig in deeper. Fourteen years later, Bayer chemist Heinrich Dreser stumbled on a treasure in the pharmaceutical archives: the work of a British chemist who in 1874 had made a little-remarked-on discovery while researching nonaddictive alternatives for morphine.
Diacetylmorphine—aka heroin—was more than twice as powerful as morphine, which was already ten times stronger than opium. At a time when pneumonia and tuberculosis were the leading causes of death and antibiotics didn’t yet exist, Dreser believed he had unearthed the recipe for an elixir that would suppress coughing as effectively as codeine, an opium derivative, but without codeine’s well-known addictive qualities.
He ordered one of his lab assistants to synthesize the drug. From its first clinical testing in 1897—initially on rabbits and frogs, then on himself and employees of the Bayer dye factory—Dreser understood that the new drug’s commercial potential was huge.
If they could pitch heroin as a new and nonaddictive substitute for morphine, Dreser and Bayer would both strike it rich. Presenting the drug to the German medical academy the following year, Dreser praised heroin’s sedative and respiration-depressing effects in treating asthma, bronchitis, and tuberculosis. It was a safe family drug, he explained, suitable for baby colic, colds, influenza, joint pain, and other ailments. It not only helped clear a cough, it also seemed to strengthen respiration—and it was a sure cure, Bayer claimed, for alcoholism and morphine abuse.
Bayer’s company doctor chimed in, assuring his fellow physicians: “I have treated many patients for weeks with heroin, without one observation that it may lead to dependency.” Free samples were mailed to American and European physicians by the thousands, along with testimonials that “addiction can scarce be possible.”
By 1899, Bayer was cranking out a ton of heroin a year and selling it in twenty-three countries. In the United States, cough drops and even baby-soothing syrups were laced with heroin, ballyhooed at a time when typical opioid consumers were by now not only war veterans but also middle-aged barbers and teachers, shopkeepers and housewives. Many were mostly functioning, doctor-approved users, able to hide their habits—as long as their supply remained steady, and as long as they didn’t overdo.
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At the dawn of the twentieth century, the pendulum began to swing the other way as a few prominent doctors started to call out their overprescribing peers. Addressing the New York Academy of Medicine in 1895, a Brooklyn doctor warned colleagues that leaving morphine and syringes behind with patients, with instructions to use whenever they felt pain, was “almost criminal,” given that some were becoming hooked after only three or four doses. “Many cases of the morphine habit could have been avoided had the family physician not given the drug in the first place,” he said. By 1900, more than 250,000 Americans were addicted to opium-derived painkillers.
And yet heroin’s earliest years were mostly full of praise, as medical journals heralded Bayer’s new cough suppressant, considering it distinctly superior to and apart from morphine, some promoting it as a morphine-replacement drug. Though a few researchers warned about possible addiction—“the toxic properties of the drug are not thoroughly known,” one noted in 1900—for eight years you could buy heroin at any American drugstore or by mail order.
In 1906, the American Medical Association finally sounded a sterner alarm: “The habit is readily formed and leads to the most deplorable results.” Heroin-related admissions to hospitals in New York and Philadelphia were rising by the 1910s and 1920s, and it was dawning on officials that addiction was skyrocketing among both the injured and recreational users (then called “vicious,” meaning their use rose from the world of vice). Soldier’s disease, in the words of New York City’s commissioner of health, had now become “the American Disease.”
The Harrison Narcotics Act of 1914 severely restricted the sale and possession of heroin and other narcotic drugs, and by 1924 the manufacture of heroin was outlawed, twenty-six years after Bayer’s pill came to market. By the thirties, typical heroin users were working-class, and many of them were children of immigrants, along with a growing number of jazz musicians and other creative types, all now reliant on criminal drug networks to feed their vicious habit—and keep their dopesickness at bay. The addicted were now termed “junkies,” inner-city users who supported their habit by collecting and selling scrap metal. The “respectable” upper- and middle-class opium and morphine addicts having died out, the remaining addicted were reclassified as criminals, not patients.
Gone and buried were the doctor-addicted opioid users once common, especially in small towns—think of Harper Lee’s morphine-addicted eccentric, Mrs. Dubose, from To Kill a Mockingbird, or the morphine-addicted mother who inspired Eugene O’Neill’s Long Day’s Journey into Night. Think of the “Des Moines woman [who] gave her husband morphine to cure him of chewing tobacco,” as one newspaper chortled. “It cured him, but she is doing her own spring planting.”
Think of the time in 1914, decades before the term “neonatal abstinence syndrome” was coined (to describe the withdrawal of a baby born drug-dependent), when a Washington official wrote that it was “almost unbelievable that anyone for the sake of a few dollars would concoct for infant use a pernicious mixture containing…morphine, codeine, opium, cannabis indica, and heroin, which are widely advertised and which are accompanied by the assertion that they ‘contain nothing injurious to the youngest babe.’”
Below the story, on the same newspaper page, appeared an ad for an opium “sanitorium,” a sprawling Victorian home in Richmond in which Dr. H. L. Devine promised that he could cure opium addiction in ten days to three weeks.
But the yellowed newspaper warnings would become moot, like so many historical footnotes—destined to repeat themselves as soon as they receded from living memory.
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Despite all the technical, medical, and political sophistication developed over the past century, despite the regulatory initiatives and the so-called War on Drugs, few people batted an eye in the late 1990s as a new wave of opioid addiction crept onto the prescription pads of America’s doctors, then morphed into an all-out epidemic of OxyContin’s chemical cousin: Heinrich Dreser’s drug.
No one saw the train wreck coming—not the epidemiologists, not the criminologists, not even the scholars who for decades had dissected the historical arc of Papaver somniferum, the opium poppy.
Like Alexander Wood promoting his syringes, and Dreser with his sleepy frogs, Purdue Pharma’s David Haddox touted OxyContin for all kinds of chronic pain, not just cancer, and claimed it was safe and reliable, with addiction rates of less than 1 percent. Haddox heralded that statistic to the new army of pharmaceutical sales reps Purdue Pharma hired. They fanned out to evangelize to doctors and dentists in all fifty states with this message: Prescribing OxyContin for pain was the moral, responsible, and compassionate thing to do—and not just for dying people with stage-four cancer but also for folks with moderate back injuries, wisdom-tooth surgery, bronchitis, and temporomandibular joint disorder, or TMJ.
The 1996 introduction of OxyContin coincided