The opioid epidemic affects just about every segment of the American population, but its most severe toll is on the former mill and mining towns of central Appalachia, where joblessness is high and many are desperate. It was among the first places hit by opioid pills (beginning in the mid-90s), and it continues to struggle. A recently published study suggests that 56 percent of Americans know someone who has abused or died of opioids.
After a broad, wide-ranging prologue, Macy zooms in to provide a more detailed history of the opioid crisis. She continues to cite scientific sources showing that a shocking 56 percent of Americans know someone who has had opioid problems. She convincingly argues that the opioid epidemic is a problem for all Americans by showing that a majority of Americans have been affected in some way.
In the Shenandoah Valley, a preschool teacher tells Kristi Fernandez that her then-four-year-old son, Jesse, is too wild in class, so a doctor suggests Ritalin. Two years later, Kristi tries Ritalin on her son, and it seems to stop teacher complaints without changing too much about Jesse.
Expanding on the story of Jesse and Kristi from the prologue, Macy looks at the sequence of events that led to Jesse’s death. The full significance of Ritalin in the story isn’t yet apparent, but it does show how social factors (like Jesse’s performance in school) intersect with medicine.
In 1997 in Virginia’s Bullit Park, near Lee County, Lieutenant Richard Stallard is on patrol. The year is an important turning point in the history of the epidemic. People haven’t yet begun locking their doors to prevent desperate addicts from stealing their things. The region, once known for widespread poverty and hunger, is now known for obesity, disability rates, and the illegal use and selling of prescription drugs. Stallard is waiting in his patrol car for an informant.
Richard Stallard shows how the opioid crisis looked to someone on the opposite side of the law from Ronnie Jones. His experiences in the mid 1990s show that, while the opioid epidemic is widely recognized today, at the beginning, there was a lot of confusion and uncertainty. This was particularly an issue for people in law enforcement, who weren’t sure how to respond to the new threat.
The informant comes up to Stallard’s car and tells him about a new drug called “Oxy,” a.k.a. OxyContin. Users have learned how to get around the pill’s time-release mechanism, giving them a massive dose all at once, with a rush similar to heroin. Stallard rushes back to check with a local pharmacist, who laments that they only just got the drug a month or two ago.
Stallard’s experience of discovering OxyContin is similar to the experience that many law enforcement officials probably had when first discovering the drug. The fact that his local pharmacist is surprised at how quickly the drug reached the black market shows that even those in the medical community were often in the dark during the early days of the crisis.
The FDA approved OxyContin in 1995. The drug is the invention of a comparatively little-known pharmaceutical company called Purdue Frederick, from Connecticut. The company is currently owned by three brothers: Mortimer, Raymond, and Arthur Sackler. They slowly grew the company, first getting into the painkiller business with an end-of-life drug called MS Contin, which is derived from morphine, and which came out in 1984. But the patent on MS Contin was set to expire in the mid-1990s, so Purdue Pharma launched OxyContin to replace the income they would lose from MS Contin. They advertised the drug heavily through their extensive network of salespeople. To advertise it, Dr. J. David Haddox, head pain specialist at Purdue, claimed that iatrogenic (meaning doctor-caused) addiction was extremely rare.
The Sackler family and Dr. Haddox are the most visible figures in the book who show how the pharmaceutical industry put profits ahead of the well-being of patients. Macy doesn’t lay this all out at once; instead she starts with biographical details. At first, the story of the Sacklers may seem mundane or even admirable—they built a successful company from humble beginnings. Their drug, OxyContin, supposedly relieves pain without any significant risk of addiction—a major breakthrough. As Macy will reveal, however, this outward appearance of achieving the American Dream is hiding a darker story.
History, however, provides several reasons to be skeptical about Haddox’s claims about OxyContin’s lack of addictive properties. Even Neolithic humans understood the power of poppy plants, and opium played a major role in two 19th-century wars between the British and the Chinese. American Civil War doctors also noticed that injured soldiers often became addicted after treatment with morphine—an addiction that affected perhaps as many as 100,000. By the 1870s, injecting morphine was a popular cure among the upper class in the United States and Europe, prescribed for a wide range of ailments, and its addictive properties continued to spark public debate.
Macy begins dismantling the rosy picture of Purdue Pharma by looking back to history. Her condensed history of opioids shows that opioid epidemics are far from a modern problem—there have been plenty of comparable events in the past. The question then becomes, if opioids have such a long history of problems, why weren’t doctors more skeptical about claims around OxyContin? Macy leaves the question unanswered for the moment, showing only how cycles of history seem to inevitably repeat themselves.
While working at Bayer in the 1890s, the chemist Heinrich Dreser created a new drug called heroin, which he hoped would replace codeine (which is derived from opium and known to be addictive). Bayer sold the drug widely, claiming that addiction was extremely unlikely.
The story of Heinrich Dreser at Bayer is presented in a way that deliberately parallels the later events at Purdue Pharma. Heroin was first developed to treat pain without causing addiction, just as Oxycontin was developed for the same purpose almost a century later.
Around the turn of the 20th century, however, some prominent doctors began to call out their peers for overprescribing. By 1900, an estimated 250,000 Americans were addicted to painkillers derived from opium. In 1914, the new Harrison Narcotics Act greatly limited the sale and possession of heroin, and by 1924, new laws banned the manufacture of heroin outright.
As with OxyContin, any good intentions behind the development of heroin are quickly overshadowed by its impact in the real world. Macy cites dates to show that the federal government was somewhat slow in responding to the heroin crisis—and the same will turn out to be true with the new opioid crisis.
Despite regulatory efforts and the so-called “War on Drugs” that began in the 1980s, in the 1990s history began to repeat itself. Purdue’s OxyContin is chemically similar to Bayer’s heroin, but in spite of the historical parallels, no one is able to predict the full extent of the epidemic it will cause.
Macy’s history of opioids in the United States is highly critical of the government. While she doesn’t dismiss the importance of government reform, this section sets up a theme that she will return to later: that when it comes to fixing the opioid crisis, people outside of the establishment (whether that means the federal government or the medical establishment) will play an important role in finding solutions.
When OxyContin arrives in 1996, one of the big trends in medicine is the idea that pain is “the fifth vital sign” (supplementing the traditional four: blood pressure, heart rate, respiratory rate, and temperature). The budget people at Purdue see the opportunity for massive profits. They push OxyContin aggressively, including making $300,000 worth of branded pens.
This passage begins with a seemingly reasonable assertion: that doctors should pay more attention to a patient’s pain. It quickly spirals into something ridiculous, however, with Purdue Pharma spending an absurd $300,000 on pens. It represents how the claims of companies like Purdue Pharma may have seemed reasonable on the surface but how they didn’t stand up to greater scrutiny.
An influential New York Times article published in 2000 further contributes to the idea that health care experts have been ignoring pain. The story does not, however, define what counts as adequate pain relief and many others in the industry struggle to define what this means. Doctors get more serious about how they treat pain, and as a result, they prescribe more painkillers. Many of these doctors don’t realize that the effects of their prescriptions will be disastrous—by 2017, the economic toll of the opioid crisis is estimated at $1 trillion.
While Macy doesn’t avoid criticizing companies like Purdue Pharma, she also shows that other factors combined to set the stage for the opioid crisis. The fact that pain as a fifth vital sign was written about in a major New York Times piece shows that the idea had fully entered the mainstream (and helps show why doctors may have ignored history and believed the fantastic claims of Purdue Pharma).
In the early days of OxyContin, there are few who raise warnings, and many of these warnings aren’t very strong. Eventually, however, a couple more forceful voices will break through: the country doctor Art Van Zee and his colleague, the Catholic nun and drug counselor Sister Beth Davies. Despite being outsiders, they are both experts at what they do.
When even major institutions like the New York Times are lining up to support the claims of Purdue Pharma, the work of pushing back against these claims will by necessity fall to outsiders. Macy shows how Van Zee and Sister Beth are both positioned to question authority (while also showing that they have the experience and credentials to back up their opinions).