The numbers are truly staggering. The National Institute on Drug Abuse estimates that 72,000 Americans died in 2017 from drug overdoses. That number is up significantly from the 64,000 who died the previous year from drug overdoses and the 52,000 the year before that. Drug overdoses now kill more Americans under age 50 than anything else. More Americans now die from drug overdoses than from HIV, guns, or automobile accidents. Moreover, there is no end in sight. Over 300,000 Americans have lost their lives to drug overdoses in the last 15 years, and experts are predicting that at least 300,000 more will die in just the next 5 years. That must give one pause.
Most of these drug overdoses involved opioids, which is why Beth Macy’s new book, Dopesick: Dealers, Doctors, and the Drug Company That Addicted America, published in August 2018, could not have come at a more critical time. It has already garnered numerous accolades—being listed as one of New York Times Book Review’s 100 Notable Books of 2018; New York Times critic Janet Mastin’s Top Five Best Books; a Chicago Tribune Best Book of the Year; a Washington Post Best Book of the Year; an Amazon Best Book of 2018; and more.
An instant New York Times bestseller, the book reveals up close the devastating opioid epidemic that has plagued this country since its inception 23 years ago via OxyContin prescriptions and the corporate greed and regulatory failure behind it. I think that it is a book that every American adult and high school teenager should consider reading. That said, it is not an easy read.
There is plenty of heartbreak between these pages, particularly when you stop to consider the lost potential of so many young lives who took their last breath way too soon. Macy takes us into the lives of the victims and also shines the spotlight on the heroes: the grieving parents who became passionate activists after their sons and daughters died of drug overdoses and some of the first responders—a few alarmed doctors, clinic workers, and pharmacists—who tried to call attention to the growing epidemic. She even turns her focus on a convicted drug dealer, whose 2-hour scheduled interview at a prison lasted more than 6 hours.
The opioid epidemic first grabbed a toehold in distressed communities in central Appalachia, as well as Midwestern Rust Belt counties and rural Maine. Macy, an award-winning investigative journalist, began reporting on the heroin epidemic for the Roanoke Times in 2012, soon standing on the front lines as she witnessed individuals and communities in her state devastated by the epidemic. She left the newspaper 2 years later to become a full-time author, and her research has now culminated in Dopesick, in which she follows the epidemic’s expansion as it crept up Interstate 81 from the traditional coal mining towns of southwest Virginia to the suburbs of Roanoke and then continued its relentless trek up the Shenandoah Valley.
Studying the epidemic from different perspectives, she identifies the factors that have combined to create the perfect storm. She lays the bulk of the blame for the national opioid epidemic on Purdue Pharma, with its mass production and aggressive marketing of its signature drug, OxyContin, after it came to market in 1996. Doctors were told that the blockbuster prescription painkiller was a nonaddictive opioid that could be safely prescribed at high dosages not just for cancer but for arthritis, postoperative pain relief, back problems, and other causes of chronic pain.
It was a new form of oxycodone and formulated to be released more slowly and therefore last longer. The company claimed that OxyContin would be less addictive than regular oxycodone because the initial euphoria—the high—would be muted because of the slow-release mechanism. The Food and Drug Administration (FDA) permitted OxyContin to contain twice the usual dosage of oxycodone based on this theory and not much else. It is worth noting that the FDA official who oversaw OxyContin’s approval later took a lucrative job with Purdue.
The introduction of OxyContin by happenchance coincided with the introduction by the American Pain Society of the concept of pain as the fifth vital sign. This meant new standards for pain assessment and treatment that put pain on the same level with blood pressure, heart rate, respiratory rate, and temperature. Pain was now to be regularly assessed and treated, even though it is a subjective measure self-reported by the patient. In 1999, the Joint Commission on Accreditation of Healthcare Organizations put the focus even further on pain relief by approving new mandatory standards for the assessment and treatment of pain. (Those standards have since been revised relating to the safe and judicious prescribing of opioids.)
Purdue surely saw the opportunity at hand. The company bought information from a data mining network, IMS Health, that allowed it to identify which doctors already prescribed the most competing painkillers and who would be most susceptible to its marketing of OxyContin. Those who were already prescribing lots of Percocet and Vicodin would find a Purdue sales rep at their door—again and again and again—to pitch about OxyContin’s potency and long-lasting action. Doctors were wooed with free meals and gifts, and the Purdue reps were incentivized with lavish perks, including $20,000 cash prizes and luxury vacations for top performers. Some were pulling down annual bonuses of $70,000. The higher the milligrams a doctor prescribed, the larger the bonuses. The strategy worked, and prescriptions began to rain down across the country. Although there were some overly aggressive prescribers, most were simply misinformed about OxyContin’s true addiction risk and under strong pressure to treat pain with medication.
It also turned out to be very easy to tamper with the OxyContin pills. It did not take long for some users to realize that the pills could be crushed or the coating dissolved so that the drug could be snorted like cocaine or injected like heroin. Without the slow-release mechanism in place, each pill basically became an instantaneous double dose of oxycodone. However, this abuse of the pills was not required for addiction to take hold. Others who were prescribed OxyContin for postoperative pain relief and back problems and followed the prescription directions also found themselves addicted in short order.
What essentially happened then is that the burgeoning opioid crisis ballooned into a heroin epidemic. OxyContin’s main ingredient is oxycodone, and because it has the same molecular structure as heroin, it acts on both the body and mind in virtually the same manner. Addiction can happen rapidly, and the withdrawal symptoms could appear within 6 to 30 hours after the last use of the drug, bringing on severe abdominal cramping, diarrhea, anxiety, nausea, and vomiting. When one or two OxyContin pills can no longer hold off that “dopesick” feeling, patients start taking more and more pills. When they are eventually cut off by doctors and OxyContin is no longer a legal option, they have to somehow get clean or start buying pills on the black market. These can retail for up to $90 a pill, which would make it a hard habit to sustain financially.
That is when the slide into heroin use occurs, with its cheap and easy availability. This is a desperate step, and the user has now entered the dark world of illicit drugs, needles, and blackened kitchen spoons. It soon became evident that a whole new demographic of users started to use heroin, including women, the privately insured, and people with higher incomes. Macy’s profiles of high school students who seemed to have a bright future ahead of them before a prescription for OxyContin led them down a far different path to heroin addiction and an early grave are particularly difficult to read.
OxyContin turned out to be highly addictive despite its slow-release mechanism, and in 2007, John L. Brownless, a young US attorney from Roanoke, settled a multistate federal suit against Purdue in a plea agreement under which the company admitted to “misbranding” OxyContin for 6 years, falsely claiming that it was less prone to abuse than quick-release versions of the drug. Three top executives pleaded guilty to misdemeanors, and Purdue paid $600 million in fines. In 2010, the FDA approved a reformulated version of OxyContin by Purdue, which was designed to deter abuse of the drug.
The Sackler family, which owns Purdue, has derived much of their wealth from this one product. In 2016, Forbes ranked the family 19th among America’s richest families, with assets worth approximately $13 billion. The family had previously been known for their generous philanthropy toward some of the world’s leading institutions, from Yale University to the Guggenheim Museum in the USA and the Serpentine Gallery to the Royal Academy in Britain, but now the family is in the press because of the thousands of jurisdictions across America that are currently suing Purdue and, in some cases, Sackler family members personally for the devastating effects of OxyContin. Last year, Purdue stopped promoting its opioid drugs to doctors and eliminated more than half of its sales force.
If the opioid epidemic began with the overprescription of opioids, the sad souls caught up in this maelstrom of addiction have far too often been left undertreated, but that seems to be changing. In 2017, President Trump declared a national public health emergency, and in October 2018, he signed bipartisan legislation aimed at curbing the opioid epidemic. The bill’s provisions will hopefully accelerate substance use treatment and research and promote medication-assisted treatment. The accompanying $6 billion in funding will also help, but is it enough? Macy’s book has provided a comprehensive and up-close look at how we got to this point in the opioid epidemic, but it is clear that there is still much to be done to stop the terrible toll that it is taking on our society.
The reviewer, Frances C. Roberts cayfrances12@gmail.com, is a freelance writer in Leesburg, Virginia.
