Review of “Dopesick: Dealers, Doctors, and the Drug Company That Addicted America” by Beth Macy

BY MATTHEW HERBERT

In 2016, the first time Tess Henry’s mother, Patricia, tracks her down in the throes of heroin addiction, Tess is using a social media app to advertise herself as a prostitute. “Sweet Sultry 26” is her handle. Out of jail and off her second attempt at rehab, Tess needs money for her next heroin fix. She is feeding a habit of six shots a day.

After two years of watching her daughter’s downward spiral into dopesickness, Patricia feared the worst when Tess disappeared from her Roanoke, Virginia home, leaving behind her toddler son. After weeks being gone, Tess was surely dead, thought Patricia. Patricia is so relieved to find even a trace of her daughter still alive, she monitors “Sweet Sultry 26” for weeks, sleeping with her cell phone. Even the picture of Tess scarred, pale and emaciated gives her hope.

Such is a parent’s love for her child.

In 2012, there had been nothing especially worrisome about Tess Henry’s life. Too the contrary, she had been a track star and honor roll student in high school. She was two years into college, studying French, gliding along on the invisible privileges that came from growing up in her wealthy suburb of Roanoke. Then, after having her wisdom teeth pulled, a doctor prescribed Tess a 30-day supply of Oxycodone.

Today, with the opioid epidemic finally in front page news, most of us would know that prescribing 30 days of Oxy for post-op tooth extraction pain would be like giving someone a bazooka to go deer hunting. When I got my wisdom teeth out 22 years ago, I got an Advil, not a month’s worth of powerful narcotics.

The path from popping prescribed Oxy pills to injecting heroin was a short one for Tess, as it has been for millions of other Americans. That first, magical euphoria of an opioid high, often experienced courtesy of a doctor’s prescription, is a feeling that rewires the brain and subjugates a person’s entire will to seeking the next fix.

These days drug dealers use this knowledge. They lace common street drugs like marijuana with powerful opioids to instantly hook the unwitting user. It’s called heatpacking.

 

dopesick

But about those doctors: their role in America’s opioid crisis is where Macy’s story begins.

The technical term for drug addiction enabled by doctors is iatrogenic addiction. The first wave of iatrogenic drug abuse, Macy tells us, happened in post-Civil War America. Hundreds of thousands of American soldiers and veterans were treated for pain by doctors who would “leave behind both morphine and hypodermic needles, with instructions to use as needed.” The resulting effects of widespread addiction were tragic and disastrous. Dopesickness that time around was called “Soldiers’ Disease.”

All opioids are derived from the the morphine molecule, the same compound found in heroin. Morphine bathes the brain in a lightness and ecstasy which, in sufficient dosage, can override the most excruciating pain. Everyone is different, but the chemical-neurological configuration of almost anyone’s brain is acutely susceptible to this feeling of rapture. Once you’ve had it, you need it again and again. You abandon everything you once held dear to seek the next fix. If you don’t, you’ll become dopesick, violently ill with fever, nausea, and pain that will not subside because the synthetic opioid you’d been using effectively shut down your brain’s receptors of natural opioids such as endorphins. You’ll wish you were dead if you can’t get more morphine.

One of the main effects of opioids is to slow down respiration. This is what users die of; when they take too much, they simply stop breathing.

In 2017, the last year for which figures have been fully analyzed, more than 70,000 Americans died of drug overdoses, most of these from opioids. For perspective, “only” 58,000 Americans died in the Vietnam War. Now we lose more than that each year to drug overdoses, and the trend is poised to climb further before it begins to subside. This is the new normal.

What unleashed such a pitiless beast on American society in the 21st century? Five factors, according to Macy’s compelling narrative.

The major push factor was the aggressive and, as it turns out, fraudulent marketing of opioids by big pharmaceutical companies, particularly Purdue, starting in the 1990s. It was an historically opportune moment for big pharma. Doctors were beginning to regard pain as “the fifth vital sign” and to treat pain seriously in its own right.

Purdue released its flagship drug Oxycontin in 1996. It was supposed to relieve severe pain without being addictive, due to its time-release property (“contin” being shorthand for “continuous”). Around the same time, the FDA loosened rules on the TV advertisement of potent drugs, and in 1998 the pharmaceutical industry’s total spending on ads surged from $360 million to $1.3 billion. Purdue pushed Oxy to doctors around the country, offering its sales reps incentive bonuses in the tens of thousands of dollars and luring doctors with Las Vegas getaways and luxury cruises. Sales reps unironically pushed Oxy on doctors as a great way to pay for their children’s college education.

Although Purdue courted doctors everywhere, they found their biggest markets in rural, poor, white America. Appalachia became Ground Zero for the opioid crisis, followed closely by de-industrialized Ohio. When globalization began to take away these regions’ jobs in the 1990s, the widespread alienation and the unemployed people’s loss of a sense of purpose created a major pull factor for opioids.

It was not just an abstract state of despair that threw former coalminers and factory workers into the maw of opioid addiction. One of Macy’s major journalistic achievements in Dopesick is to have sleuthed out the pathway that systemic unemployment took toward widespread addiction. After Appalachia’s main employers cast off the people who had done decades of hard labor in mines and factories, these newly unemployed pursued medical disability as a means of survival. It was as natural for doctors to use the new wave of pain management techniques to treat them as it was for the people to seek them.

This pattern of disability-seeking dovetailed with an increasingly dominant American narrative, that there is a pill for every complaint. Again, though, there were concrete factors at work behind this abstract attitude. A major environmental factor leading to the opioid crisis was the fact that so many Americans were already on pills. This factor (1) helped normalize the idea of medicating almost anything, and, more importantly (2) enabled millions of Americans to trade their old, legal drugs for new, illegal ones, a criminal transaction known as diversion.

As we increasingly medicate a myriad of life-long conditions starting in childhood, we should note a sobering fact which Macy observes: “Almost to a person, the addicted twentysomethings I met had taken attention-deficit medication medication as children, prescribed pills that as they entered adolescence morphed from study aid to party aid.” Some traded Adderol for marijuana, Ritalin for cocaine. A doctor Macy interviewed reported how normalized prescription drug use by children has become in recent years. As a YMCA camp doctor in the 1970s, about one percent of the kids he saw came to camp with prescribed meds. This figure jumped to 10 percent in the 1990s, and by 2012, a third of his campers were showing up with prescriptions, “mostly ADHD medications, antidepressants, and antipsychotics.”

The decisive factor in Macy’s narrative is the widespread determination to see drug addiction as a sin, which calls for cathartic forgiveness and total abstinence, rather than a sickness which calls for evidence-based treatment. We are now far enough into the opioid epidemic to understand its defining statistics. The main one staring us in the face, Macy tells us, is the effectiveness of medically assisted treatment of addition, which means the use of prescribed proxy drugs (such as methadone or suboxone) which, in a supervised setting of addiction treatment offers the best hope for recovery.

Critics of MAT object that it basically replaces one opioid addiction with another, and furthermore, addicts can, and often do, divert their prescriptions for heroin or other narcotics. The pitiless statistics of recovery, however, indicate nonetheless that MAT offers the only viable path toward recovery. It replaces an untreatable addiction with a treatable one.

Moralistic Americans, including some members of the medical, legal, and law enforcement communities, are fixated on the emotionally-satisfying image of a short detox program followed by lifelong sobriety–a road to Tarsus conversion. But this model simply doesn’t work. A Harvard research tells Macy, “What happens is, it takes about eight years on average, after people start [detox] treatment, to get one year of sobriety . . . and four to five different episodes of treatment” to achieve durable sobriety.

Advocate of MAT tout not its higher success rate (closer to 50 percent), but also its overall effectiveness in harm reduction. Any of the dozens of parents of dead addicts in Dopesick would tell you they would prefer even a lifelong protocol of supervised suboxone use by their recovering children to the callous, lethal ideology of cold-turkey detox.

Lurking beneath the facts, trends and statistics that Macy lays bare is the sinister suggestion that America’s power elite regard those dying of drugs as disposable people, and that their disappearance is a positive good. This admittedly outlandish-sounding conclusion actually springs from the confluence of three common ideologies that remain stubbornly popular in America.

The free-market ideology says consumers want whatever they want–good or bad, right or wrong–and that an efficient market simply responds to their demand signal. If the demand happens to run fundamentally counter to the consumers’ interest, it will eventually cancel itself out. We see this ruthless market correction in the 70,000 plus who die annually of drug overdoses. The irrationality of poor consumer choices is simply extinguishing itself.

All-out libertarianism tells us each individual must be protected in his right to make the choices that suit him. It is wrong to intervene politically in such basic decisions. Nannying free people away from free choice is the thin end of an authoritarian wedge, which we should not tolerate. In a country where we imprint on our license plates “Live free or die,” we must be prepared to accept that some people will die as a result of exercising their freedoms.

Finally, religious fundamentalism says we get what we deserve based on the way we live our lives before a divine judge and that, in any case our god(s) will set things right in the long run. If we deserve comfort in an afterlife, we will get it.

Tess Henry died of blunt-force head trauma and was thrown into a Las Vegas trash dumpster. The proximal cause of her death, as nearly as the police could determine it, was a blow delivered by her pimp/dealer. After weeks shooting up on the streets of Vegas, Tess owed more for her heroin supply than she could make turning tricks.

But the way Macy tells the whole story of opioid addiction in America, I can’t help but comment on a more distal cause of Tess Henry’s death. It was, to my mind, a confluence of bad ideas–the three just mentioned. We have so brutalized the idea of human worth in our society that, to stay true to our ideas, we must believe that Tess got what she deserved, and that her mother, Patricia, sleeping with her cell phone when she got the call on December 30th, 2017, got what she deserved. The perfect forces of a free market at work delivered up this result, and it is not for us to call the result good or bad, still less to ask our government to get involved in parenting our children to prevent this kind of outcome. If there is a right or wrong to be adjudicated in the system of free, individual choices that led to Tess’s death, we surrender that task to God in his wisdom.

 

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