OxyContin pill bottles scattered in front of protestors of the opioid crisis. (AP Photo/Patrick Semansky)

The reality of life in a "Dopesick" country: "It is just a state of misery"

Salon talks to author Beth Macy about the economics, regulatory failures and racism that fueled the opioid crisis


Chauncey DeVega
August 24, 2019 3:00PM (UTC)

Millions of Americans are addicted to prescription opioids such as OxyContin and other drugs. Many of these people will "graduate" from using prescription pain pills to heroin and other illegal narcotics. 

At least 400,000 Americans have died from opioid overdoses since 1996. It is also estimated that at least 200,000 Americans have died from overdoses from prescription opioids such as OxyContin.

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In many ways opioid addiction is a function of social disorganization — joblessness, lack of access to proper health care, crime, broken families, and diminished upward mobility and overall life chances — in many American communities. America's opioid problem also makes many of these communities problems much worse. And there is the spillover effect as well: the "deaths of despair" among the white "working class" voters in these opioid infested areas moved them to vote for Donald Trump where in a moment of backlash, rage, and selfishness they forced their literal as well as emotional and psychological pain on to the American people as a whole.

The opioid addiction problem in America is also a manifestation of "narcocapitalism" where multinational pharmaceutical corporations saw wealth in human misery and pain and as always chose profits over people. Legal theorist Laurent de Sutter explains this as part of a broader dynamic where, "every capitalism is necessary a narcocapitalism — a capitalism that is narcotic through and through, whose excitability is only the manic reverse of the depression it never stops producing, even as it presents itself as its remedy.

In her bestselling book "Dopesick" investigative journalist Beth Macy documents the human cost of the opioid addiction and how Big Pharma created, identified, and then exploited a market for "pain management" with devastating consequences for entire communities across America.

In our conversation, Macy explains how companies such as Purdue Pharma gathered and exploited data about doctors to then market powerful opioids such as OxyContin on unsuspecting patients who knew little about the addictive properties of the pills they thought would help them. Macy also details how individual doctors were seduced and won over by  pharmaceutical companies into prescribing these news types of highly addictive and powerful opioids — and then how many of those same doctors failed to intervene to help their now addicted patients.

What role do opioids play in rural red state and Rustbelt America where people look around their communities and see death and despair, and the right-wing evangelical churches are preaching the End Times, and Fox News is broadcasting hate, anger and fear?

I believe that this is going to be the number one challenge the United States faces. There are rural areas where the jobs have gone away. The pharmaceutical companies purposely targeted those areas when OxyContin came out. The companies purchased the data which showed them where in the United States that opioids were already being prescribed — and this happened to be areas where there were large numbers of workplace injuries. The pharmaceutical companies then went to doctors in those areas and told them that OxyContin was safe.

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The data which was featured in the Washington Post showed that 76 billion pills were sent to such areas of the country. When you look at the worst-hit communities per capita, these are places where the pharmaceutical sales reps went in and told these lies. They were able to find doctors to work with. Who do people trust? They trust their doctors. The companies purposely lied to the doctors, who then prescribed the pills in those communities at the same time the jobs were going away.

It was a perfect storm of not only people getting addicted very quickly — because there has never been a drug, an opioid, this strong before — but also the users start diverting the drugs because they were in such oversupply. The pills were being sold on the black market as a way for desperate people to pay their bills. This was much the same way that their ancestors had done with moonshine.

There is also this circular dimension to the problem where jobs disappear from these communities but employers will not relocate and hire there because prospective employees will not be able to pass a drug test.

What is the intersection between emotional pain and physical pain for the people you interviewed and got to know for your reporting in "Dopesick"?

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If you have addiction in your family, for example parents or grandparents, then you are 50% more likely to be a person for whom an opioid lights up your pleasure center.

We also know that people who don't have things they're passionate about in life are also more likely to become addicted. This is true in both rich and poor areas. The difference is that a person from a wealthier family is more likely to be able to access treatment to turn the situation around. Whereas in a rural community not only do they have no money for treatment but there are not as many treatment options available.

And there is this hyper-conservative fire and brimstone bias against treating the addicted as patients worthy of medical care. Instead addicts are treated like moral failures and criminals. And so you have jails filling up. I was just in a community in North Carolina last week where they're having to pay the adjacent County $750,000 to house surplus inmates. They give them no treatment while they're in jail, and when they come out, the courts put them on probation, and as soon as these people who have not received treatment fail the drug test they are put back to jail. While in jail they get no treatment for their withdrawal symptoms, their dopesickness. Where's that hope in that?

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How do the executives and other senior personnel in these pharmaceutical companies which are selling opioids to these communities rationalize their behavior?

Those corporate CEOs, salespeople, researchers and the like would say that they are helping chronic pain patients in need. They actually say and believe such things. Vanity Fair recently profiled David Sackler. He is the grandson of the Sacklers who started Purdue Pharma. He complains that his four-year-old is getting bullied at school.  Another of Sackler's relatives had to move from Manhattan to Florida because people were saying, "Why did you create the opioid crisis?" Sackler goes and he lists all the things Purdue has done to stop diversion and abuse of the drug. None of it was sufficient. And to hear somebody say, "Look at all the good Purdue has done" indicates to me that Sackler gets no feedback other than from the paid sycophants that he surrounds himself with.

In these rural communities hit by the opioid epidemic it is just a state of misery. I was visiting my little nephews in rural Ohio — which has the second[-highest] overdose death rate in the country — and we were getting chili dogs at this little hot dog stand in a former factory town. We were going to the park and the 11-year-old says, "No Aunt Beth, we don't want to step on heroin needles." And literally this is a town where nobody used to lock their doors. Rural America has changed so much.

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There are so many moral hazards in this story of America's opioid epidemic. First, people are addicted to pills by companies making money from their sickness. In turn there are few if any jobs in these communities so the people there are self-medicating. Then there is mass incarceration and for-profit prisons which make money from locking people up who do not have access to drug treatment. It is dystopian.

I think it is the reality of late stage capitalism. For example in a former coal mining region in West Virginia the largest employer is now the prison. The whole system is set up to trap people in a cycle. This is not just federal prison but also the local jails as well.

Is there any moment of stepping back where the corporations and their management say to themselves, "Maybe this isn't the best thing for these communities?" Or is it always profits over people?

Consider whistleblower Karen White, hers was the only case out of all those scores of civil cases to actually go to court. She has one lawyer and Purdue has a team of lawyers. She was a sales rep for Purdue Pharma in the early years and she's told to go out to these doctors that they already know about. She has the data. She sees what are the first "pill mills" in Florida. The sales reps have been given training which says, "Here are the signs of diversion and abuse. If you see people in the waiting room with needle marks, track marks in their arms, you should turn them in." She follows those rules and is called on the carpet for it. Karen White brings the first whistleblower case and she loses. White is also told she can't ever speak about the case again or she'll have to pay the legal fees.

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The sales reps were incentivized by the company. The more milligrams they talked a doctor into prescribing — "If this person is on 40, but you can get them to 80" — the bigger the bonus check that went into their bonus calculations. And I have a deposition from one of the lawyers asking Karen White in a deposition for a civil case, "Well what happened when you did see diversion and abuse?" And she said, "Well they set up the policy such that if I did turn in a pill mill doctor, if I had made some bonus from that same doctor the year before, I would have to give it back." The whole program was designed for promoting and marketing these drugs as being safe when they were not. The company lied.

Where were the regulators? Why did the FDA let them say it was safe when it wasn't or that these drugs are believed to reduce the risk of addiction and abuse? They let them say that for six years. Where was the DEA when they're sending 9 million pills to a town of 400 people in Kermit, West Virginia? The United States government allowed these corporations to police themselves. It is always going to come back to profits over people — and that is exactly what happened.

There are people who are working with these regulators and then they end up retiring and then going to work for the pharmaceutical industry. The same thing is true with the DEA. So that person from the DEA has intimate knowledge of exactly how the organization works, right? So he can teach his new colleagues how to skirt the regulations. I mean there are just so many places in this story where the epidemic could have been slowed or perhaps even stopped. This is a story of repeated regulatory failure.

What of the Hippocratic Oath and "Do no harm"? Do these doctors who are over-prescribing these opioids actually believe that they are doing the right thing? Or does the money override their morality?

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They find out who the doctors most likely to be prescribing opioids were and also who already were doing so. And then the companies would go to them and find out what they liked. The pharmaceutical companies are buying the doctors' time. If you were a doctor who loved Cuban cigars, they’d show up with Cuban cigars as a gift. Remember Purdue sent 5,000 doctors, nurses, and pharmacists to resorts wearing OxyContin branded beach hats. At the same time, some of these early overdosed dead were overdosing in the high school library. And the few doctors that complained got branded as kooks. One of the things that also was shocking to me was how patients would return to their doctors showing signs of addiction. The reps would tell the doctors that this isn't addiction, this is actually a "condition" made up by Purdue called "pseudo-addiction." The cure for which was, of course, more OxyContin.

Once people get addicted the doctors have a hard time managing them. The doctors do not have a lot of time. I'm sure plenty of doctors thought they were doing the right thing. Because it wasn't just Purdue, it was also the whole "Pain is the fifth vital sign" movement — which was partly funded by Purdue. And then there was the emergence of the "Rate your doctor online" phenomenon. Many doctors were afraid to cut people off from opioids because they thought they'd get a bad rating or review. And some hospitals even cut a doctor's reimbursements if they get bad ratings.

No one ever starts out wanting to be an addict, do they?

When I was coming up, I'm 55 now, we were drinking, smoking a little weed. But had I come of age in the mid or late 1990s it would have been very different. Now they're trading pills around. There is a huge correlation between people who start off taking ADHD medications who then become comfortable with pills. There is a pill for every ill. This also coincides with there being more pharmaceutical ads on TV. It is a feedback loop.

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Almost to a person, every one I wrote about that initially got addicted either took pills that were left over from their parents or grandparents, or started out with ADHD medication that was prescribed to them. And then in high school when they're recreationally using alcohol or drugs they are trading their ADHD medicine for stronger pills. Or they're taking their ADHD medicine so they could stay up all night drinking.

How does chronic pain from an injury at work or a car accident, for example, become addiction to opioids?

Consider Tess Henry. She was a waitress who had experienced some bumps in her life. She worked at a high end restaurant, the kind that you see written up in magazines. She's probably drinking too much already at the time. She gets a bad case of bronchitis and goes to an urgent care center. This is 2012, she is 20 or 21 years old.

She is given two 30-day prescriptions for opioids. One is hydrocodone for throat pain and the other is cough syrup with codeine in it. By the end of 30 days she's sick and she searches her symptoms online and realizes, "Holy crap! I'm addicted. I'm probably addicted!" She was already experimenting a bit but this is really the moment she goes into full-blown addiction.

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Tess starts to look for ways to find the pills on the black market. And of course she doesn't have to go very far to find somebody who knows somebody who can get her the pills. And then very shortly after that, the pills got harder to get. So that's when her dealer says, "Hey, guess what? I got a lot of this. Pills are getting really expensive, but I've got heroin now. And you start taking it just like you took the pills, you smash it up and snort it." To her it didn't seem like "Oh, I'm doing heroin." It was more "Oh this is how I took the pills. Crush it up and snort it." Before Tess knew it that wasn't enough to keep her from being jittery and dopesick. Then the dealer teaches her how to shoot it up. That story happens over and over again. It is very common.

How do people "graduate" from pills to heroin? What is that process like?

It's very much the way Tess Henry describes it in the book. Once you're addicted you start feeling dopesick.  Every user I talked to described that feeling as being like the worst flu, times a hundred, and not just symptoms of nausea, diarrhea, vomiting. There is also crushing anxiety and depression because you've been medicating all these feelings right? So all that comes back to you, too. But they are so afraid of being dopesick. And then before they know it they start snorting the heroin just the way they snorted the pills. Then they start shooting up. It's all driven by that outsized fear of not being dopesick.

There is now all this public empathy and sympathy for white folks who are suffering from has now come to be described as the "deaths of despair" across red state, Rust Belt and rural America. Where is the sympathy and empathy for poor Latinos, and black folks, and First Nations brothers and sisters who are suffering from addiction, job loss, and lack of opportunities?

White folks are getting all of this sympathy and concern for being addicted to opioids and heroine and other drugs but black and brown folks get thrown in jail.

This is an "iatrogenic" or doctor-fueled wave of addiction. Doctors do not trust black people to responsibly take pills. So purposely, because of old fashioned racism, black people were not  prescribed pills in the way that the same doctors prescribed pills to white people — especially working-class white people. Now what we are seeing are overdose deaths in urban areas being higher among minorities. This is largely because they get the heroin that's been cut the most times with fentanyl. Many people in urban areas are coming out of jail and they have had no drug treatment while incarcerated. When they use again now they're getting heroin with fentanyl in it. They're opioid naive. This has fatal results.

What would justice look like?

Justice would  be all the manufacturers, dispensers, and distributors of opioids who profited so mightily paying for the downstream damage that this mass over-supplying of opioids has caused across the country — and particularly in rural communities where overdoses can be as much as 65% higher than the national average, and where they have fewer resources to address these problems, as well as fewer jobs. Ultimately justice is the treatment for addiction being as readily available as the opioid pills once were.


Chauncey DeVega

Chauncey DeVega is a politics staff writer for Salon. His essays can also be found at Chaunceydevega.com. He also hosts a weekly podcast, The Chauncey DeVega Show. Chauncey can be followed on Twitter and Facebook.

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