“When a new drug sweeps the country,” writes Beth Macy in Dopesick: Dealers, Doctors, and the Drug Company That Addicted America, “it historically starts in the big cities and gradually spreads to the hinterlands, as in the cases of cocaine and crack.” In the case of the opioid crisis in the US, though, she claims it “began in exactly the opposite manner, grabbing a toehold in isolated Appalachia, Midwestern rust belt counties, and rural Maine.”
This, in part, was by design. Shortly after Purdue Pharma debuted the prescription painkiller OxyContin in 1996, its massive sales team got ahold of data to figure out which physicians were most susceptible to aggressive marketing. If a doctor was already prescribing a high amount of pain pills like Vicodin, Macy reports, they would be more likely to be open to their pitch claiming OxyContin was a safer, less addictive alternative. And the doctors who most often fell into this category? They were in rural, small town America.
By 2007, when Purdue paid $634 million in fines for its deceptive marketing practices, the damage was done and the worst drug crisis in America’s history was underway. According to the National Center on Health Statistics, more than 254,000 people died from an opioid overdose between 2007 and 2016, and overdoses in general have become the leading cause of death for Americans under 50.
And, as Macy shows in her urgent, likely definitive book on the subject, the response to the crisis has been lackluster at best. In the meantime, some experts expect that between 500,000 to 650,000 people will die from opioid overdoses over the next ten years.
Macy, a former journalist for The Roanoke Times in Virginia and a 2010 Nieman fellow at Harvard University, received wide praise for her first book, Factory Man (2014), which zeroed in on how globalization has affected American workers (Tom Hanks is set to produce a HBO miniseries based on the book). Dopesick, her third book, is at its best when chronicling how heroin took hold of the US after a crackdown on prescription opioids, and her numerous, tragic interviews with people with addiction and their families who were ravaged by these drugs.
I recently spoke with her about Dopesick and we talked about, among other things, the cycle of opioid addiction, how doctors have contributed to the epidemic, and why more medication-assisted treatment (or MAT) for opioid addiction is desperately needed.
What is it about being sick—and just the craving for opioids—that is so central to this cycle of addiction?
I think a lot of people still don’t understand that issue. I've had journalists say they didn’t get it until they read the book. But it’s this idea that, once you are addicted to opiates, you’re not going after the drugs to get high—not really at all at that point. What you’re doing is trying to avoid being super dopesick. Time after time, I would hear how the feeling of withdrawal is just the worst. Flu times 100, diarrhea, nausea. And that feeling just overtakes any judgment you have, any mother’s love for her child, for instance, any craving for sex. It's the relationship that the user develops with the drug and that comes first over everything if you’re trying not to be so sick.
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How was Purdue Pharma able to push OxyContin so aggressively for so long? They had huge influence over doctors, you report, and their sales reps used a lot of shady tactics, right?
First thing they did when they introduced the drug is hire this huge, huge sales team. And they went out across the country to promote the notion that OxyContin was basically safe. Addiction was only supposed to be in like 1 percent of cases—it was supposed to be exquisitely rare.
They hired doctors to promote this notion. Understand that the [Food and Drug Administration] allowed them to do this initially. It was this squishy claim that it’s believed to reduce the chances for addiction and abuse because it has the time-release mechanism. So the FDA allowed them to make that claim. Then Purdue poured all kinds of money into exaggerating and promoting that claim.
So they hired 5,000 doctors, nurses, pharmacists to become paid speakers, and they sent them to these pain management seminars and speaker training seminars where they were then told to go back to their communities to deliver the message that addiction was rare with the drug. They spent a lot of money doing this. The reps flew to a lot of doctors with briefings, gave them trips and even ridiculous stuff like OxyContin-branded beach hats. At the same time, people were overdosing on OxyContin in their high school, in their libraries, in Appalachia.
And didn’t they use data to specifically target rural communities?
Yes. They bought data from this company called IMS Health, a firm that keeps track of what prescriptions are being prescribed and where. The data showed which doctors in this community were already prescribing a lot of painkillers, and those tended to be in distressed rural areas where there had been extracting industries like mining, furniture factories, logging, and fishing.
So they sent the sales reps to those communities that were high opioid prescribers, but of much less strong doses at the time. They were now competing against the immediate-release opioids like Vicodin and Lortab. And they were going into these doctor offices who were already prescribing these for legitimate pain patients, and they were saying, “No, look. OxyContin is better. It lasts over 12 hours.” They said it was less abusable than an immediate-release pill.
And to add insult to injury, the thing that the company did when they started to hear reports of abuse and people started complaining that it should be taken off the market, they always blamed it on the abusers. They always blamed it on the coal miners and the young kids that were abusing OxyContin. Never on the drug itself or the fact that they had misrepresented the drug. They just never took responsibility.
You write about how so many doctors’ views on pain at the time OxyContin was introduced played a big role in the crisis. Could you talk about that?
The generally held belief at the time was this notion of pain as the fifth vital sign. And at the same time, Purdue funded a lot of these pain foundation groups and these pain management physician associations. But that was part of Purdue’s strategy, too. Remember that I quote from the budget plan where they're taking advantage of this idea that pain is a vital sign. They're taking advantage of joint commissions of hospital accreditation bureaus that’s now changing hospitals and whether they are going to be reimbursed on "how did they treat your pain?" And consumer surveys were starting to happen—almost like Yelp reviews for physicians. And doctors don’t want to get a bad score, right? Because it could hurt the hospital’s reimbursement chances.
This was the perfect storm between the job losses [in the distressed areas], the pain as a vital sign, and these very aggressive marketing tactics all combined with this new opioid drug, the strength of which had never been seen in America.
Do you think physicians—who caused a lot of this mess—are doing enough now to get us out of it?
I do not. I think that any doctor who took a free item from any opioid pharmaceutical company should feel morally compelled to help us get out of this. By that I mean, there aren’t enough addiction treatment doctors. There aren’t enough general doctors or OB/GYNs who have bothered to become waivered to prescribe Suboxone, for instance, which along with methadone are some of the best chances people have for getting into recovery and avoiding an overdose. We need to get people healthier so that they can live in recovery. And study after study shows that that is the way to do it, but because of these regulations about needing special training to make this happen. Well? It makes no sense.
A lot of doctors don't want to do these things, to be honest, because they don't want addicts in their waiting room. They don't want to have to deal with them. They're difficult cases. The doctors I know that do this are doing things like working through their lunch break and working late into the night. They simply have too many patients and just care.
You write that this epidemic has ravaged people of all economic classes, but isn’t it much, much harder for poor people to pull themselves out of it?
Absolutely, and especially in these rural areas in states where they haven’t passed the Medicaid expansion. Overdose rates in these distressed areas are still the highest compared to other places. Just basic healthcare would be so helpful—you know? At the end of the book, I spend a couple of days with this mobile free clinic that travels in a Winnebago throughout Wise, Virginia, and Lee County, Virginia. You just see the needs of people waiting for the van so they can get new blood pressure medicine. I mean, just basic healthcare.
It was interesting how so many young people you interviewed who became heroin users started out with misusing their ADHD meds—like Adderall. Why do you think that is?
I think ADHD has been way, way over-diagnosed and over-prescribed. A lot of parents want their kids to have the best advantage. And why do kids often want ADHD medication that don’t maybe need? It isn’t just to study. They were taking them so they could stay up all night drinking, for instance. Two-thirds of all college seniors have been offered illicit prescription drugs in college. We've got too many pills out there, basically.
You advocate for more medication-assisted treatment (MAT) for opioid addiction, which combines therapy with medications like buprenorphine —a drug that reduces the cravings for opioids. Why is there still such a stigma around people trying MAT?
I think N.A. and A.A. and other abstinence-only models believe it’s just giving one drug for another drug—you're not truly clean unless you’re on nothing. I watched Tess [a drug user profiled in the book] struggle in these N.A. meetings that we went to together. Nobody would sponsor her, because they didn't think she was clean because she was taking buprenorphine. That’s insane and was really hurtful to her. She just stopped going. [Editor's note: Tess was found murdered in Las Vegas in December 2017.]
The worst part of the crisis right now seems to be street fentanyl getting cut into things like heroin and pressed into pills. What are some of the factors that played into its rise in the US?
Yeah. There’s medical fentanyl, obviously, such as prescribed fentanyl patches. But the difference from that and the crisis we’re in the middle of now is fentanyl coming in from China, largely being mail ordered over the Dark Web. Complete with pill presses. Where I live in Roanoke, a kid was arrested this year for attempting to sell pounds of “Xanax” bars, which were actually laced with fentanyl. Think about if that would have gotten out there—kids buying Xanax and it’s actually fentanyl. It’s bad. I just think there needs to be more policing of the stuff coming in the mail and leadership on a federal level and every level.
Donald Trump declared the opioid crisis a public health emergency in October 2017. Yet, it seems that the administration really hasn’t done anything since then. And he stopped short of deeming it a “national emergency,” which he previously promised to do, and would have released federal funds almost immediately to address the issue. In your mind, what things can the government do more of?
Kind of a sleight of hand on Trump’s part, right? He didn’t authorize any new authority or funds. There was the Chris Christie collaboration and the creation of an opioid commission. They made 56 policy change recommendations and I don’t think very many, if any, have been followed up on. And some of the money that was promised, the last I checked, only around 25 percent had been actually funneled down to local communities. Our local community service board in Roanoke, for example, which is supposed to be providing MAT, the last time I checked, they had 21 people. And they only allow you to be on MAT if you’d already done the counseling program and failed. To me, that’s criminal.
This interview has been edited for length and clarity.
Correction 8/20/18: This story has been corrected to reflect that Tess was prescribed buprenorphine, not medical fentanyl. It has also been updated to include Tess' death.
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