Dopesick: Dealers, Doctors, and the Drug Company that Addicted America

“The addicted were now termed ‘junkies,’ inner-city users who supported their habit by collecting and selling scrap metal. The “respectable” upper- and middle-class opium and morphine addicts having died out, the remaining addicted were reclassified as criminals, not patients.”

Macy provides historical context to show how drug use went from being normalized to being criminalized. Her attention to shifts in representation of people who use drugs helps her develop the theme of Race, Place, and the War on Drugs.

“Purdue handpicked the physicians who were most susceptible to their marketing, using information that bought from a data mining network, IMS health, to determine which doctors in which towns prescribe the most competing painkillers. If a doctor was already prescribing lots of Percocet and Vicodin, a rep was sent out to deliver a pitch about OxyContin’s potency and longer lasting action. The higher the decile—a term reps used as a predictor of a doctor's potential for prescribing whatever drug they're hawking—the more visits that doctor received from a rep, who often brought along “reminders” such as OxyContin-branded clocks for the exam room walls.”

Macy’s description paints Purdue Pharma’s marketing campaign for OxyContin as one that surgically targeted doctors who were already overprescribing drugs and thus contributing to addiction to prescription drugs. Tactics like these support Macy’s argument that the opioid epidemic is the result of corporate greed.

“In an Appalachian culture that prides itself on self-reliance and a feisty dose of fatalism, peddling pills was now the modern-day moonshining. Some passed the trade secrets down to their kids because, after all, how else could they afford to eat and pay their bills?”

Macy connects aspects of Appalachian culture in the past to its problem with opioid addiction in the present. In addition, she highlights that a lack of work has created an economic context in which people in Appalachia are likely to divert opioids.

“If history was any indication, the moment OxyContin and other opioid pills became too expensive or too cumbersome to get, illegal drug peddlers would step in to fulfill the market demand, just as they had done a century earlier when heroin became illegal. For centuries, dealers of opium, morphine, and heroin understood that an addicted person’s fear of running out—of becoming dopesick—portended one hell of a business model.”

Macy believes the opioid prescription epidemic mutated into a heroin epidemic because of market forces and the biology of addiction. Her use of the term “business model” highlights the economic motivations of people who sell opioids, but this particular passage makes no distinction between drug dealers and Purdue Pharma. The implication is that Purdue Pharma is so driven by corporate greed that it is willing to take advantage of the destructive force of addiction.

“That meeting pitted Van Zee, wearing his only suit and a Jerry Garcia necktie his mother had given him, against Purdue executives and some of the nation’s top pain-management experts, most of them acknowledging that they were or had been paid speakers for Purdue. Van Zee found himself outnumbered nineteen to one, a harrowing experience for a loner not accustomed to public speaking.”

One of the dynamics of capitalism in the United States is that it is difficult for individuals to counter decisions made by corporations; the ascendence of corporations in the American political and regulatory system meant that the normal controls to stop unethical marketing of an addictive drug didn’t work. Macy dramatizes the power differential with this description of the contest between Van Zee and Purdue Pharma.

“The corporation feels no pain.”

This quote from United States Assistant Attorney Andrew Bassford captures the frustration government officials and families felt when Purdue Pharma received fines and community service for mid-level executives responsible for misleading marketing of OxyContin. That lack of pain is in contrast to the pain of family members on display during the sentencing portion of United States v. Purdue Pharma (2007). Macy uses this quote to support her argument that the epidemic reflects a broken system on the regulatory level.

“But the larger question about hope continued to reverberate wherever I went. I heard a version of it from an overwhelmed family friend, who pulled me aside at a wedding party to tell me about her thirty-four-year-old addicted daughter and pleaded with me through tears: ‘Just tell me one thing, what can your book do to help me keep my daughter alive?’”

This encounter is an appeal to emotion that helps the reader understand the desperation of family members seeking to understand opioid addiction. Most readers will be persuaded of the urgency of finding answers about the opioid epidemic. This quote also helps Macy communicate the primary purpose of her text and an important part of the audience for the text.

“No one was paying attention to heroin arrests when they only concerned the children of inner-city black families.”

Macy identifies misconceptions and stereotypes surrounding who uses drugs and where they use them as one of the reasons that white suburban parents were unprepared to recognize opioid use by young people. These biases are one of the results of the War on Drugs.

“But mostly they kept quiet about it, shut down in their grief and their shame.”

Once suburban parents recognized drug addiction in their families, stigmatization of drug addiction as an urban and/or Black problem impeded them in two ways. It made them less likely to understand that their family problems reflected systemic problems in approaches to addiction, and it left them feeling stigmatized because they failed to live up to the suburban family ideal. Macy blames these two forces for ineffective responses to the suburban stage of the opioid epidemic.

“In rural counties decimated by globalization, automation, and the decline of coal, the invisible hand manifested in soaring crime, food insecurity, and disability claims. In Martinsville and surrounding Henry County [Virginia], unemployment rates rose to above 20 percent, food stamp claims more than tripled, and disability rates went up to 60.4 percent.”

Macy contends that the interaction of complex forces created the opioid epidemic in rural America. Here, she describes economic forces in Appalachia that changed the culture of work and self-reliance that defined Appalachia in the past.

“We were safe in our ignorance, or so we thought—content to stereotype drug addiction as the affliction of jobless hillbillies, a small group of inner-city blacks, and a few misguided suburban kids. But another invisible hand was upon us.”

Macy includes herself with the use of the first-person pronoun. That rhetorical choice helps readers see her as a concerned citizen and parent, thereby helping to establish her credibility on the topic. The “invisible hand” (126) is an allusion to 18th-century economist Adam Smith’s concept from his influential work The Wealth of Nations. Smith argues that self-interest will make the wealthy circulate wealth, which will in turn benefit society as a whole; contemporary critics of this concept call it “neoliberalism” and believe as Macy does that relying on self-interest to regulate markets related to necessities like healthcare leads to bad corporate behavior by companies like Purdue Pharma.

“The real perfect storm fueling the opioid epidemic had been the collapse of work, followed by the rise in disability and its parallel, pernicious twin: the flood of painkillers pushed by rapacious pharma companies and regulators who approved one opioid pill after another. Declining workforce participation wasn’t just a rural problem anymore; it was everywhere, albeit to a lesser degree in areas with physicians who prescribed fewer opioids and higher rates of college graduates. As Monnat put it: ‘When work no longer becomes an option for people, what you have at the base is a structural problem, where the American dream becomes a scam.’”

Macy relies on the words of experts to deliver her harshest critiques. Here, that approach allows her to paint Purdue Pharma as a greedy corporation that ignored American belief in the importance of hard work to success. Monnat’s credentials (a professorship at Syracuse University) and Monnat’s stinging reproach of corporations allow Macy to use appeals to knowledge (ethos) and emotion (pathos) to enhance her argument on the larger economic context of the epidemic.

“NIDA, the Institute of Medicine, the World Health Organization, and the White House drug czar’s office would all agree that indefinite (and maybe even lifelong) maintenance treatment is superior to abstinence-based rehab for opioid-use disorder. And even Hazelden, the Betty Ford–affiliated center that originated the concept of the twenty-eight-day rehab, changed its stance on medication-assisted treatment, or MAT, offering Suboxone to some patients in 2012.”

Macy relies on an impressive group of authorities to advance the contested position that medication-assisted treatment is much better than 12-step programs. Macy believes a bias for 12-step programs is hampering the ability of volunteer organizations that partner with law enforcement to support recovery from addiction.

“Shit did not stop.”

This is a phrase Jones used as he continued to arrange drug sails while incarcerated. Macy uses the profane phrase to reflect the gritty, dangerous nature of drug trafficking. It captures the relentless nature of people with addiction seeking more of the drug, law enforcement’s efforts to catch dealers, and families’ efforts to help their addicted loved ones.

“[T]he reformulation had almost certainly been prompted by the fact that Purdue was losing its patent on the original formulation.”

When Purdue Pharma does finally institute changes to make OxyContin less likely to be abused, they are driven by profit instead of ethics. Macy uses points like these to show the role of corporate greed in the opioid epidemic.

“The system is too rigidified, as [President James] Garfield would say, not nimble enough to combat heroin’s exponential growth. The drug’s too addictive, the money too good. ‘You whack one dealer and the others just pop right up, like Whac-A-Mole.’”

Whac-A-Mole is a game in which the player has to bop the head of a mole who pops up in different holes at a rapid pace. This simile is likely to be an effective use of figurative language because it helps the reader understand the situation of law enforcement as it struggles to keep up with drug distributors. Macy uses vivid phrases like these for chapter titles and important concepts, creating a shorthand that helps the reader keep the many forces at play in the opioid epidemic in mind. That kind of shorthand is also typical of journalistic style, so this diction reflects Macy’s professional background.

“For several months in early 2016, I drove Tess and her baby to Narcotics Anonymous meetings, recording our interviews (with Tessa's permission) on my phone as I drove and walking the baby around the back of the meeting room when he cried.”

Maintaining objectivity is an important part of journalistic ethics; in this passage, Macy shows how difficult maintaining objectivity became in the face of such struggle and suffering. Macy reminds the reader that she does have ethics—she asks Tess before recording her—but that the depth of Tess’s needs moved her to action. Her insertion of herself in the text provides a model for readers who feel cautious about less punitive approaches to addressing the opioid epidemic.

“She had been to twelve-step meetings before, both AA and NA, but felt stigmatized for being on view for buprenorphine, which many participants perceive as not being clean, or simply as replacing one opioid with another—a cultural gulf that only seemed to widen in the two years I followed Tess. Although NA’s official policy was accepting of MAT, longtime NA members who were asked by the meeting leader to sponsor or mentor Tess politely declined—a shunning that must have ‘felt like daggers to her,’ a relative later said.”

One aspect of the broken system in rehabilitation programs is the stigmatization of medication-assisted treatment for opioid addiction in specific “Narcotics” Anonymous meeting rooms. In Tess’s case, this stigma made her miss out on support she needed to stay sober. The impact of this stigma on Tess helps Macy support her belief that the overreliance on 12-step programs is contributing to the opioid epidemic and relapses into addiction.

“‘We can’t arrest our way out of this problem,’ I'd heard again and again, from everyone from police chiefs to public health providers. But that sentiment seemed to apply only to the mostly white group of opioid users who were dealing or committing property crimes to stave off dopesickness—not to people like Ronnie, in prison for armed heroin distribution, or to the majority of other black and brown people arrested for selling drugs, even though they were statistically less likely to use or to deal. (Three-quarters of federal drug offenders are black or Hispanic, while 57 percent of state and prison drug offenders are people of color).”

Macy uses statistics here to provide a more nuanced critique of Jones’s belief that racism explains in part why he is receiving the blame for heroin addiction in rural Virginia. Racially disproportionate incarceration is one of the effects of the War on Drugs; while Macy believes Jones’s excuses are self-serving, she accepts his description of the larger context for his incarceration.

“If, as Shannon Monnat had proposed, the hollowing out of the predominantly white working class was the kindling in the heroin epidemic, and the mounds of opioid pills in America’s communal medicine chest was the spark, I was beginning to wonder whether the fragile transition of ten thousand prisoners a week from state and federal prisons into U.S. communities fanned the flames of the fire.”

A major argument in the book is that the opioid epidemic is the result of a broken system created because of unintended consequences. A work release program brought Jones to rural Woodstock, Virginia, making him the connection between urban America and rural America in this case. His role in the heroin epidemic in rural Virginia provides evidence that readers should question assumptions about race and place when it comes to the War on Drugs.

“He clings to the narrative that he was providing an actual service—offering the drug cheaper and in a much safer environment than Baltimore. Like Purdue Pharma announcing it had created the perfect time release painkiller that was addictive in “less than 1% of cases” and then a reproaching the hordes of addicted people who misused its drugs, Ronnie had an easy time shifting the blame, with responsibility often lost in the cloudy penumbra of bureaucratic disconnects and cops and dealers Whac-A-Mole.”

The similarity between Jones’s profit-driven motivation and that of Purdue Pharma is Macy’s way of saying Purdue Pharma acted just as irresponsibly as Jones. The similarity between the man and the company reflects the interaction of multiple broken systems—criminal justice, government regulation, and the economy.

“While Ronnie turned gray in prison and Kristi prepared the next seasonal decorations for Jesse's grave, the Sacklers’ rank among ‘America’s Richest Families’ slid from sixteenth to nineteenth on the Forbes list.”

Macy uses irony to show that dealers and grieving families are bearing the cost of greed rather than the powerful family behind OxyContin. This passage appeals to readers’ sense of fairness, making it more persuasive to readers who may not completely agree that the company is to blame. By referring to the Sacklers specifically, Macy is putting a face to the responsible parties.

“The economist had assumed the free-market economy would operate efficiently as long as everyone was able to work for his or her own self-interest, but he had not foreseen the elevation of rent-seeking behavior: the outsized greed of pharmaceutical companies and factory-closing CEOs, and the creation of a class of people who were unable to work.”

Macy paraphrases an economist to show how Purdue Pharma’s greed has broken capitalism. Readers who place greater emphasis on economic arguments over Macy’s appeals to emotion are likely to be swayed by the diction and concepts of this passage.