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Two decades after health officials in Southwest Virginia sounded the alarm about the devastating impact Oxycontin was having on the region, hard numbers confirm that drug manufacturers and distributors carpet-bombed Central Appalachia with the powerful drug and other opioids.
An investigation by the Washington Post shows that pharmaceutical distribution of the opioids oxycodone (the narcotic in Oxycontin) and hydrocodone grew by more than 50% from 2006 to 2012. On a per capita basis, rural Central Appalachia was an outsized target of that distribution.
One person who is not surprised by the findings is journalist Beth Macy, author of Dopesick: Dealers, Doctors and the Drug Company that Addicted America (Little, Brown and Company). Her 2018 book starts with Oxycontin’s arrival in Southwest Virginia in the 1990s and the pleas of healthcare professionals there to the Food and Drug Administration to do something before it was too late.
Macy’s 2018 book has just been released in paperback. A new discussion guide provides some information on what has happened since the hardback version was released last year. In the new section, Macy argues again for greater emphasis on medical treatment for addicts, rather than relying on criminal-court measures to address the epidemic.
We last talked to Macy in January 2019. Now we wanted to get Macy’s reaction to the current spate of state-government lawsuits against Oxycontin manufacturer Purdue Pharma and the new reporting from the Washington Post.
Macy continues to cover opioid addiction. She has a forthcoming article in The Atlantic, and she’s done an Audible documentary about Tess Henry, a central character in Dopesick. The Audible production will be released in October.
Tess, as Macy identifies her in the interview below, became addicted to Oxycontin after a doctor prescribed the powerful painkiller for a routine ailment. Tess’ story follows a familiar path of Oxycontin addicts: from legally prescribed medication, to illegally procured medication, to street drugs like heroin. A 2014 study found that the three-quarters of heroin addicts said the first opioid they used was a prescription drug. Overdose deaths involving heroin climbed more than 600 percent from 2007 to 2017, according to the Centers for Disease Control and Prevention.
Tim: Let me start with a question about the Washington Post and whether you’ve had a chance to look at any of the data. Does it confirm any of the things you spent years reporting on?
Beth: Absolutely. To me, anybody in Central Appalachia would look at that data and would say, “Duh. Duh.” I mean, it was shocking, the numbers. But I wasn’t surprised, at all. I’m surprised by the Washington Post, just now, saying this is a major story. …
Tim: So the issue has not received the attention it deserves?
Beth: I still don’t see the urgency. …
Tim: I think back to how the Purdue criminal case in federal court in Virginia was settled in 2007, relatively early in the whole arc of this story. And, as you say, there was little sense of urgency about their illegal branding the drug so many years ago. It didn’t change things?
Beth: Right. And it’s worse now. And, in fact, Purdue sold even more Oxycontin after that settlement. The U.S. Attorney who prosecuted the case in western Virginia thought that the message from that would be that this drug is always dangerous. He hoped there would have a slowing effect. He didn’t take it off the market. And, in fact, if you go back and you look at those stories about [the 2007 settlement], very few people mention that, “Oh, in fact one of the punishments is that Purdue isn’t going to be able to get business with Medicaid, Medicare, and Tricare as a punishment.” But actually that punishment was for the holding company, Purdue Frederick, not Purdue Pharma. [So Purdue Pharma could continue to manufacture and sell Oxycontin.
And then, Purdue just simply double downed on their marketing and they sold even more Oxycontin the next year. And I think a lot of people just thought, “Oh, well we’re done. They picked up a big fine.” Of course, it was really just getting started.
Tim: Do you feel like we’re getting any closer to people understanding what’s at stake and who’s responsible? Is any of that changing with the lawsuits and the criminal complaints on the state level?
Beth: Yeah, I mean there’s so much media about it that I think that there is an understanding of the role that big pharma played in this. I think most people have gotten that message, although still people tell me, “I didn’t know Oxycontin and heroin were related until I read your book, that they were chemical cousins.” But still, there’s a lot of education that needs to be done.
Tim: Your book Dopesick is just coming out in paperback. What has changed since Dopesick was published in 2018?
Beth: Well, I just feel what I hear and see from my own reporting and by going out in the middle of the country now. Things have slowly started to change, while we still need a lot more dollars to put toward treatment. [One estimate is that it’s] going to take $80 to $100 billion to turn this around, and that’s the level of what happened with HIV and AIDS funding. The Trump administration has added like $3 billion. But he said he fixed it. He fixed the opioid crisis. It’s a joke. So there’s a lot more work to be done. And frankly, I don’t think that whatever we get from the opioid lawsuits are going to be anywhere near that amount. But it could make a difference if it’s all handled responsibly.
I have some new reporting coming out in The Atlantic in December about a treatment innovator from Kentucky who’s working in Indiana now and is trying to get the criminal justice system on board with healthcare to help these folks so they’ll stop this cycling in and out of jail. There are people making some really good innovations now.
We know what works, because we’re starting to see reduced deaths in places like Rhode Island, Massachusetts, and Vermont. If you have one person in power who’s willing to step out on a limb and see these people as human beings, and make policy, it can make a huge difference.
In the reader’s guide [to the new paperback edition], I talked about the head of the emergency department at Carilion Roanoke Memorial Hospital. Six hospitals in western Virginia, and how he didn’t believe in MAT [medication-assisted treatment], and didn’t think it was his job, and so they’re basically just NARCAN-ing people [administering NARCAN, naloxone, which treats opioid overdoses] and sending them out into the street with no help at all, no follow up, and can you imagine someone doing that to somebody having a heart attack.
So I heard the head of the emergency department changed his mind, and I called him up and he said, “Yeah, we read your book, and then we looked into the research and we said, ‘how can we not be doing this?’“ So now he’s got 24/7 a doctor in the ER, waivers to prescribe enough buprenorphine [an opioid used to treat withdrawal symptoms] to get them to their bridge appointment with the outpatient provider. And when you ask him how he feels about it he says, “I feel like doing cartwheels every day because we’re having success with it. We’re not seeing the same people over and over.”
When I was in Burlington, Vermont, I saw the same response. In Burlington, the police chief, who supported the mayor and hired an opioid response director, of course, they’re an early Medicaid expansion state. And they realized that out of the 34 overdose deaths, every single person had some into contact with police [before their deaths]. So they decided that they’d de-criminalize heroin and even if you’re selling just to use, they don’t arrest you for that, they actually take you to treatment, and the opioid response director sort of oversees it like a social worker. And they talk about every single person, every two weeks in a meeting, and their overdoses went down 50% in a year … 50%. So we know what works, we’re just not doing it to scale to match the scale of the epidemic.
Tim: You’re out there talking to a lot of different groups and I’m just curious if you can summarize what the response is with these different communities that you’re visiting.
Beth: Well it just depends. We’re such a varied country. When I go to small towns, people would come up after and they’d say, “It’s even worse than you said.” So when I go to a city, there’s always people, … usually sitting in the front row, that are crying because they’ve lost loved ones.
A truck driver in Maine said he had lost 15 people. He’d been in recovery I think two years now. He said he hadn’t been able to cry about any of it until he read about Tess at the end of my book.
[Author Robert Gipe] said he was talking about how Purdue should pay reparations to Appalachia and somebody [in recovery who had read Dopesick] came up to him afterwards … and said, “I didn’t understand that I was part of a bigger story until I read that book. Before I read that book, I thought I was just a f— up.”
Beth: That’s the way I felt too. Because it’s a slow-motion story, and people didn’t get it. Even people who were intimately involved in it. So, I’m grateful for those comments.
One woman reached out to me and she said she was reading the book and her sister had been in recovery for two years and she was getting to the part she thought Tess was going to die, but she didn’t know. And the woman kept saying, “Oh, we’re so lucky, we’re so lucky.” And before she finished the book, her sister relapses, OD’s and dies. She was in Indiana and I was going to be speaking in Ohio the next week or maybe two weeks later, wasn’t long at all, and she and her dad came over to meet me. I still think there’s a huge amount of stigma and that people were suffering are grateful that people are talking about what’s happened and they’re not just seeing these human beings as addicts and criminals and moral failures. They’re seeing that it’s that it’s part of a larger story of greed and putting profits before people.
Tim: Tell me about these other projects you have going.
Beth: I have an audio documentary coming out by Audible on October 3rd (2019), and that is taking Tess’s story and telling it, but in her own words, you hear her. I recorded all our interviews not knowing I was going [to use them in an audio program]. After her death, her mother and I decided to try to retrace her last steps. So we went up to Las Vegas once by ourselves and we went another time with an Audible producer. We found the person who found her body in the dumpster. We found people she had crossed paths with who had helped her. We interviewed the police. We wrote about the homeless addictive community in Las Vegas, which is a lot different than being homeless in Roanoke. It’s really rough out there.
She told her mom she was being gang-stalked. No one in power even would admit that that was a thing, but we interviewed a lot of people who used to be on the street and they told us all about it. We learned a lot about her final days and weeks that were both worse than we thought and, in some ways, better than we thought in that she did have a community out there.
There’s also something that, as a journalist you don’t really get to go back and take a hard, hard look at something such that when I was listening to her, the very first time I interviewed her in 2015 when I’m listening to her with my 2019 ears, I’m saying, “Oh she knew exactly what she needed.” She talked about urgent care for the addicted. That’s what’s happening now at Carilion. Instead of being thrown out into the street, they’re actually treating them now. She was trying so badly to get home, to get on Methadone. Anytime she lost access to her [medicine-assisted treatment] things spiraled downhill. And when you look at it, knowing what we know now, you can see that she knew exactly what she needed.
We’re sad but there’s some happy things at the end of it. Her mother is now raising her son. They talk about Tess every night. “Tess loves you.”