Dopesick: Dealers, Doctors, and the Drug Company that Addicted America (Little, Brown and Company, 2018) by Beth Macy. 

Beth Macy’s book about the opioid crisis in southwest Virginia contains plenty of tragedy — families decimated, lives lost or ruined, proud communities brought to their knees.  

The biggest tragedy of all, of course, is that the story could have turned out differently.

In the earliest days of the crisis, prophetic voices in rural Virginia sounded the alarm. The pharmaceutical manufacturer whose criminal marketing practices helped launch the epidemic didn’t listen. Nor did federal regulators, until the genie was out of the bottle.

Macy traces the epidemic from the coalfields of Appalachia to the affluent suburbs and small towns of the Shenandoah Valley. Her role as a working journalist based in the region gave her access to the people who know the story — addicts and their families, dealers, law enforcement, medical professionals, and community activists. Her skill as a reporter and writer combine to give the reader a direct connection to the crisis and its human cost.

I talked to Macy last month to get information on how Purdue Pharma, the manufacturer of the pain pill OxyContin, marketed their pill across regions and demographic groups. (In addition to corporate officers’ guilty plea in federal court for how they marketed the pain pill, states have filed civil suits against the company and its owners over the drug’s role in the opioid epidemic.) The conversation below, which is edited for length and clarity, is from that telephone interview.


Tim Marema: Dopesick begins with the introduction of OxyContin into the southwest Virginia coalfields by its manufacturer, Purdue Pharma. The drug was different and the way the medical profession was prescribing opioids was different. How so? 

Beth Macy: In the hundred years prior to Oxycontin coming out, we pretty much knew that all opioids were addictive, and we only used them in cases of very severe pain, cancer, and end of life. What Purdue and lobbyists that they put a lot of money into, and other opioid makers and distributors did, was they flipped the narrative that it was now safe to treat pain, moderate pain, not just severe and end of life. 

TMJ, lower back pain. Who doesn’t have lower back pain? Osteoarthritis, all these things were now safe [to treat with painkillers], so you had kids getting wisdom teeth out and being sent home with 30 oxycodone or OxyContin. After five days of being on the stuff, you can actually be addicted. They basically flipped the narrative, and the Food and Drug Administration allowed Purdue to do that because they allowed them to say that [the drug was safe] because of this brand new time-release mechanism, which meant it was supposed to bleed out over 12 hours. 

Marema: Introducing OxyContin into southwest Virginia in Central Appalachia was an intentional marketing decision of the drug manufacturer, right?  

Macy: Well, what the company did was it bought prescribing data from IMS Health [a medical data company], and so they knew which places in the country were already prescribing the most competing opioids such as Percocet and Vicodin. They knew where their best chances of success were, and they were in the kind of towns that had high rates of disability and already had people with legitimate pain, [places that had work injuries from] logging, mining, fishing in Maine, coal, furniture factories. It was worse in those places. 

Because of the economic desperation and just because of the nature of pain, users quickly figured out an end run around the 12-hour time-release mechanism [that the manufacturers said made OxyContin safe]. 

Marema: The geographic arc of the opioid problem is different from customary drug-crisis patterns. Rural America played a different role. How would you describe where rural America fits into the opioid epidemic? 

Macy: Well, unlike most drug epidemics, which historically began in the cities, this one started in rural areas, especially rural areas in decline, because the company bought that prescribing data. That’s where OxyContin-related crime [first] became a problem, in these rural areas – people who had previously been on opioids for pain and had been able to get off OK, because they were treated for shoulder injury or whatever. This drug was different. It was so much stronger than the drugs before. You saw people like farmers, and coal miners, and loggers stealing from their families. It’s the same thing you see with the kids doing heroin, and the 20-somethings doing heroin now, stealing from their family, prostituting, just behavior that is not like the people. It just knows no demographic bounds, this molecule.  

Marema: You say that the abuse of the narcotic began quickly after it hit the market. 

Macy: It took me a half an hour to find the first cop that found [OxyContin] being diverted on the streets, almost immediately after its introduction, because people were walking around with orange and green stains on their shirtsleeves. They figured out that if they held the pill in their tongue, the coating will come off, and the coating contained the time-release mechanism, and then they would brush it off, the coating. The orange was the 40 [milligrams], the green was the 80. They’d brush it off on their shirt. The cops said you would see it everywhere. Then you start to see people stealing in order to buy it once they were hooked, committing crime on a level that these small towns had never seen before. 

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It also became a way to numb pain for people, and a way not to be dope-sick once they were hooked, but also a way to pay their bills. You had some people who weren’t hooked but realized that, if they could get their doctor to write them an Oxy, they could make a lot of money, a dollar a milligram on the black market, kind of like moonshine was in the old days. It’s a side hustle. 

Marema: The opioid problem didn’t stay in southwest Virginia, however. It moved up I-81 to the suburbs and cities of the Shenandoah Valley. Eventually, heroin dealers from the coasts saw the unmet demand for narcotics in these relatively small places and moved in. You described Roanoke as the place where all these stories met. Tell me what you mean by that. 

Macy: Yeah, so we’re about a quarter of a million [population in Roanoke], if you count the outlying county, and we’ve got Virginia Tech nearby, and we’re kind of a wannabe city. We’re always wanting to be Charlotte or Asheville, or something like that. We’re sort of the southern end of the Shenandoah Valley, and we have I-81, kind of connecting them all, kind of close to Central Appalachia, parts of it, for sure. That also happens to be the route where the drugs travel, where the heroin comes in from Harlem and Philadelphia and Baltimore. 

I’ve played with that idea of these connecting ends, and really just the way I went at it was I picked stories that moved me. I knew it started out in Central Appalachia, and I knew I wanted to write about the people fighting back, and heard about Dr. [Art] Van Zee, and went down and interviewed him, and Sister Beth Davies, and the first pharmacist to call Purdue on the phone, the first cop to see it being diverted, which is really cool to kind of get into the anatomy of the early story. Then, as a reporter at the Roanoke Times, which had been covering the story 25 years from there. In 2012, I wrote about heroin breaking out in Hidden Valley, which is this lovely suburb outside of the city, 10 minutes from [Roanoke]. 

These two upper middle-class families, their lives had been upended by heroin. One 19-year-old had died of overdose, and the other was going to prison for his role in selling the heroin that ended his former private school classmate’s life. His life was now ostensibly ruined too. Readers, back in 2012, they had no idea. It just wasn’t in the news every day. They’re like, “What?” Literally, spitting up their coffee, “What? Wealthy white kids are doing heroin?” I actually pitched this book to my agent in New York, after I wrote Factory Man (Back Bay Books, 2014) but before it came out. He was like, “No, heroin isn’t a thing. Roanoke’s just late getting it,” which is pretty funny. It shows you what a bubble people are in. 

Marema: You have quite a bit about the media, some of which shows a failure to put the pieces together to see beyond individual incidents to the larger picture. I recall the mother who was talking to a newspaper editor saying, “Please don’t just do stories on my son robbing the bank. Do a story on what’s going on with heroin. That’s the story.” 

Macy: Right, and that was up in the Shenandoah Valley. If we would have paid attention to the canary in the coal mine, when they were happening 10 years earlier, things like that were happening then in Appalachia … I’m thinking of the pharmacy robberies, and grocery manager gets shot and killed because somebody wants to rob him as he’s making the night deposit, that’s happening 10 years earlier in West Virginia, and then it starts happening in this kind of nicer farm town, and nobody sees the fear of dope-sickness that’s propelling it. 

They only see this good-looking 19-year-old kid robbing a bank, and so the mom goes out, begs the newspaper. “Kids are using pills and heroin now. Nobody comes to our meetings.” She’s telling the science of it, how once you’re addicted you have this outsize fear.  She says, “It’s like if you haven’t eaten in three weeks and somebody puts a delicious plate of food in front of you and tells you you can’t eat it.” She’s trying to kind of just break down how the opioid receptors in your brain get hijacked by this drug, and nobody asked her a single question. They were more interested in this crazy crime your son committed. 

Marema: If there had been a different response to where the story really was, if the press had been in a position to engage this issue more thoroughly and be out there covering those stories, do you think the arc of the story could’ve been different? 

Macy: I do. That’s a perfect example. Nobody went beyond the headlines. If you talk to the police or even the judges, they’re like, “Yeah, 80% of the stuff on our dockets is drug related,” and yet, if they don’t bother to go deeper than just the story that they sat in the courtroom covering for 40 minutes, you don’t really know that that’s what’s fueling it. The community doesn’t. 

I ran into a federal judge in a Kroger parking lot, and this was as I was finishing up the book, and I was like, “Hey, judge. How’s it going?” We both just start commiserating about heroin in the region. He’s like, “I can’t get any coverage of it. Nobody’s covering this trial.” It was a huge trial, and people just had no idea, ’cause there just weren’t enough people to cover it. 

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